UNIVERSITY  OF  CALIFORNIA 
AT   LOS  ANGELES 


GIFT  OF 

BIOLOGY  DEPART!;!! 


\ 


NOTES 


HOSPITAL  PRACTICE 


PART    I. 


PHILADELPHIA  HOSPITALS. 


SELECTED  AND  ARRANGED  BY 

SAMUEL  M.  MILLER  M.  D. 


PHILADELPHIA,  PA. 
SAMUEL  M.  MII.LER,  M.  D.,  Publisher. 


COPYRIGHTED,  iSSi 


v,  i-z 


PREFACE. 


The  following  diagnostic  and  therapeutical  notes  have, 
many  of  them,  been  condensed  and  collated  by  me  from 
my  reports  of  clinical  lectures  and  notes  of  hospital 
practice,  which  have  appeared  originally  in  the  New  York 
Medical  Record,  New  York  Hospital  Gazette,  Boston  Medi- 
cal and  Surgical  Journal,  Philadelphia  Medical  Times, 
Philadelphia  Medical  and  Surgical  Reporter,  Cincinnati 
Clinic  and  Scientific  American;  while  others  are  now 
i*-  published  for  the  first  time.  Every  effort  has  been 

t     made  to  secure  accuracy,  and  it  is  hoped  that  the  "Notes" 

5 

will   prove  of  service  to  the  busy  practitioner,  for  whom 

they  are   mainlv  intended.  THE  PUBLISHEKt 


248911 


GENERAL  DISEASES. 

SOME  INTERESTING  POINTS  IN  THE  DIAGNOSIS  AND  PROGNO- 
SIS OF  TYPHOID   FEVER. 

The  case  was  that  of  a  sailor,  admitted  to  the  hospital  on 
the  27th  of  January,  who  had  been  in  good  health  until  four 
days  before  his  admission,  when  he  complained  of  chilliness, 
of  fever,  and  of  nausea,  but  of  no  headache.  His  nose  bled 
profusely,  and  his  bowels  became  very  loose.  Upon  his  ad- 
mission his  face  was  singularly  flushed,  and  he  had  a  severe 
pain  in  his  back.  His  temperature  was  104^°  F.,  his  pulse 
92,  and  his  respirations  24  to  the  minute.  Nothing  could  be 
detected  in  the  condition  of  the  lungs  to  account  for  the  heavy 
flush  on  his  face.  Upon  examining  the  urine  it  was  found  to 
contain  granular  hyaline  casts  and  bladder  epithelium.  It 
was  re-examined,  with  the  same  result. 

The  man  remained  in  the  same  condition,  with  morning 
remissions  and  evening  exacerbations,  and  with  a  few  bronchial 
rales  in  his  lungs,  until  the  afternoon  of  the  day  after  his  ad- 
mission, when  profuse  epistaxis  supervened,  and  the  character- 
istic rose-colored  spots  appeared  on  his  abdomen,  which  grew 
swollen  and  tympanitic.  Stitt  there  was  no  headache.  On  the 
evening  of  January  31st  the  man's  temperature  was  103°  F. 
Between  January  27th  and  February  1st  there  was  never  a 
difference  of  more  than  one  degree  between  morning  and  evening 
temperatures.  On  the  morning  of  February  1st  the  pulse  was 
only  84,  and  the  respirations  20  to  the  minute.  The  tongue 
was  of  the  characteristic  appearance— dry,  cracked,  reddish  at 
spots,  devoid  of  coating,  varnished-looking.  The  typical  spots 
on  the  chest  and  abdomen  were  slightly  raised,  and  disappeared 
upon  pressure.  There  was  some  gurgling  in  the  right  iliac 
fossa,  and  a  moderate  amount  of  abdominal  distention.  The 


4  Notes  of  Hospital  Practice. 

bowels,  after  admission,  were  easily  controlled  by  a  single 
opium  suppository  daily. 

On  February  1st  the  face  was  still  flushed.  The  breathing 
was  rather  harsh,  and  there  were  a  few  dry  rales  in  the  lungs. 
Still  no  headache,  and  intellect  clear. 

Dr.  DaCosta,  in  his  examination  of  the  case  on  February 
1st,  and  remarks  upon  it,  developed  some  points  of  much 
novelty  and  interest. 

The  first  sound  of  the  heart  he  found  to  be  very  feeble,  and 
there  was  most  marked  throbbing  of  the  vessels  at  the  root 
of  the  neck.  He  considered  the  case  to  be  different  from  the 
great  majority  of  cases. 

He  wished  to  lay  great  stress  upon  the  presence  of  albumen 
in  the  urine  upon  the  eighth  day  of  the  disease.  The  case 
would  have  to  be  very  closely  watched.  The  presence  of  the 
albumen  might  be  explained  in  either  one  of  two  ways — (1) 
there  might  have  been  pre-existing  disease  of  the  kidneys  as 
a  complication  of  the  fever,  or  (2)  the  typhoid  fever  had  pro- 
duced the  disease  of  the  kidneys.  If  the  latter  alternative 
were  the  true  one — and  it  so  seemed  to  him — the  case  was  a 
veiy  grave  one,  for  the  albumen  was  noticed  as  early  as  the 
fifth  day  of  the  disease.  Early  albuminuria,  as  a  symptom, 
never  occurs  in  the  course  of  typhoid  fever  unless  the  case  is  to 
be  a  very  grave  one.  Albumen  is  quite  commonly  found  in 
the  urine  of  typhoid  fever  patients  in  the  third  week  of  the 
disease.  The  slight  difference  between  morning  and  evening 
temperatures  so  early  in  the  attack  was  anotJier  bad  sign. 

Furthermore,  the  first  sound  of  the  heart  was  thus  early 
altered.  Alteration  in  the  first  sound  of  the  heart  does  not 
usually  occur  until  late  in  the  course  of  the  disease.  When 
Hie  heart  is  affected  early,  it  becomes  a  warning. 

In  closing,  Dr.  DaCosta  wished  to  call  attention  to  the 
existence  of  flushed  face,  without  any  disease  of  the  lungs.  It 
always  was  enough  to  raise  suspicions  as  to  the  nature  of  the 
disease,  especially  when  accompanied  by  great  throbbing  of  the 
vessels  at  tfie  root  of  the  neck.  This  fact  had  struck  him  many 


General  Diseases.  5 

years  ago,  and,  upon  entering  a  sick  room  and  finding  these 
coincident  symptoms,  he  used  to  make  a  rough  diagnosis  of 
typhoid  fever  at  once,  without  any  further  examination. 

All  these  symptoms  being  as  they  were,  it  was  determined 
to  shape  the  treatment  accordingly.  Up  to  February  1st,  the 
man  had  been  taking  f  §  iij  of  whiskey  daily.  This  quantity 
was  at  once  increased  to  f  |  v.  Together  with  this,  gtt.  x  of 
muriatic  acid  was  given  every  four  hours.  The  daily  dis- 
tributed dose  of  quinia  was  gr.  x.  The  man's  diet  wus  very 
carefully  regulated,  consisting  principally  of  beef-tea  and 
milk.  Diarrhoea  was  checked  by  opium  suppositories.  The 
patient  was  sponged  morning  and  evening  with  tepid  water. 

Fe6.  20£A. — The  man  is  now  convalescent,  having  been 
carried  through  the  attack  by  careful  treatment.  The  albu- 
minuria  has  disappeared. 

SOME  INTERESTING   CASES  OF  TYPHOID   FEVER,  AND  THEIR 
TREATMENT. 

The  following  cases  occurred  among  the  sailors  of  the  Rus- 
sian steamers  which  were  built  and  repaired  during  the  sum- 
mer and  fall  of  1878,  on  the  Delaware  river  at  Philadelphia: 

Out  of  550  sailors,  30  were  attacked  with  different  grades 
of  typhoid  fever.  During  the  months  of  September,  October, 
November  and  December,  these  cases  were  brought  to  the 
German  Hospital.  They  were  all  seen  by  the  attending  phy- 
sicians, Drs.  Turnbull,  Woodbury  and  Cohen. 

With  the  assistance  of  Dr.  Hermann  and  of  the  Russian 
physicians,  it  was  determined  to  ascertain  the  cause  of  the 
outbreak.  The  majority  of  sick  sailors  came  from  one  steamer, 
and  as  their  drinking  water  was  different  from  that  of  the 
officers,  the  first  chie  as  to  the  cause  of  the  disease  was  thus 
found.  Examining  into  this,  right  in  the  immediate  vicinity 
of  this  steamer  a  privy  was  found,  a  large  part  of  the  excre- 
ment frDm  which  found  its  way  into  the  water  from  which 
the  sailors  drank.  On  the  other  steamers  this  state  of  things 


o  Notes  of  Hospital  Practice. 

was  not  found  to  exist,  but  the  excrement  and  dirt  on  board 
was  thrown  over  into  the  river,  from  which  they  at  first  ob- 
tained their  drinking  water.  Surmising  this  to  be  the  cause 
of  a  few  cases  of  the  disease  they  resorted  to  another  source 
for  their  water,  which  caused  the  disappearance  of  the  disease. 
The  interesting  cases  brought  into  the  hospital  were : 

B.,  set.  23,  robust  constitution,  entered  the  hospital  after 
feeling  out  of  sorts  for  five  days.  From  his  own  statement, 
the  prominent  symptoms  were,  intense  headache  and  great  heat 
in  the  evening ;  did  not  seem  to  know  the  condition  of  his 
bowels,  nor  could  any  other  symptom  be  obtained  from  him. 
On  entering  the  hospital  he  presented  the  following  condition : 
Great  headache,  high  fever,  temperature  103°  A.  M.,  104°  P. 
M.,  pulse  90  to  100,  skin  hot  and  dry,  great  thirst,  bowels 
constipated,  tongue  heavily  coated  with  a  dark-brown  fur — 
deeply  fissured,  tenderness  in  right  iliac  fossa,  no  tympanitis 
and  no  eruption.  He  remained  in  this  condition  for  seven 
days ;  on  the  eighth  day  he  became  delirious,  necessitating  his 
being  tied  with  shackles ;  he  refused  to  take  any  nourishment 
and  would  not  respond  to  any  command.  His  temperature 
rose  to  105°  and  his  bowels  were  moved  with  an  enema. 
On  the  twelfth  day  his  delirium  became  active,  wild,  and  after 
a  heroic  dose  of  morphia  hypodermically,  he  appeared  rational 
the  next  morning ;  his  bowels  were  moved  every  third  day 
with  an  injection ;  never  once  having  the  slightest  tendency 
to  diarrhoea ;  the  injections  acted  very  rapidly.  On  the  four- 
teenth day  after  admission  his  temperature  fell  to  104°  P.  M., 
103°  A.  M. ;  less  headache,  the  skin  still  hot  and  dry ;  tongue 
heavily  coated  with  a  dark  fur — deeply  fissured;  no  rose- 
colored  spots  could  be  found  on  the  body,  and  his  bowels  were 
still  constipated.  Late  in  the  evening  signs  of  approaching 
delirium  seemed  evident  and  he  was  given  a  large  hypodermic 
injection  of  morphia;  he  slept  well  after  the  injection  of 
morphia  and  appeared  rational  the  next  morning. 

He  continued  in  this  condition  until  the  twenty-first  day, 
when  his  temperature  rose  to  105°,  with  great  tympanitis,  and 


General  Diseases.  7 

diffused  abdominal  tenderness.     He  lost  consciousness  and  died 
the  same  evening. 

Autopsy. — Body  was  much  emaciated.  Lungs  consolidated 
posteriorly,  (hypostatic  pneumonia.)  Spleen  enlarged  and 
softened.  Peyer's  patches  were  in  different  stages  of  inflam- 
mation, some  swollen,  others  sloughing  and  others  having 
nothing  but  peritoneum  for  the  floor  of  the  ulcer.  No  per- 
foration was  found.  This  was  what  would  be  called  one  of 
the  grave  forms  of  typhoid  fever,  though  the  temperature  did 
not  reach  above  105°.  He  was  systematically  fed,  but  the 
emaciation  in  the  last  few  days  was  very  great. 

The  following  is  a  good  illustration  of  what  has  been  called 
an  insidious,  latent,  or  ambulatory  form  : 

G.,  set.  37,  was  working  at  his  usual  duties  as  a  sailor, 
noticing   nothing   abnormal   except  a  slight  diarrhoea,  which 
caused  so  little  disturbance  as  to  pass  unheeded.     As  he  him- 
self expressed  it,  his  bowels  were  opened  only  once  more  than  - 
usual  during  the  day.     He  had  no  evening  heat,  no  lassitude, 
nothing,  in  fact,  that  would  lead  one  to  think  he  had  typhoid  ; 
fever.     All  of  a  sudden  he  felt  a  sharp  pain  in  the  abdomen,  . 
which,  in  a  few  hours  grew  unbearable;    his  belly  became 
very  tympanitic  and  tender  to  the  touch  ;  his  temperature  was 
103°,  P.  M. ;  rose-colored  spots  were  found  on  the  abdomen. 
He  now  presented  all  the  symptoms  of  acute  peritonitis  and  was 
treated  with  opium.     He  died  in  twelve  hours  after  his  ad- 
mission. 

Autopsy  revealed  ulceration  of  Peyer's  patches  in  the  third 
week,  with  a  large  perforation  in  an  ulcer  near  the  ileo-eoecal 
valve;  recent  lymph  over  peritoneum  and  bowels,  indicative 
of  peritonitis.  Spleen  enlarged  and  softened ;  other  organ* 
found  healthy. 

In  addition  to  these,  there  were  some  very  mild  cases,  which 
would  be  classed  under  the  head  of  abortive  variety.  Three 
cases  of  this  kind  presented  themselves,  .with  the  following 
symptoms  and  course : 

Some  lassitude ;  headache,  which  increased  in  intensity  in 


8  Notes  of  HospUul  Practice. 

the  evening;  temperature  102°,  p.  M.,  100°,  A.  M, ;  pulse,  90 
to  100.  Very  little  diarrhoea,  stools  thin  in  consistency  and  of 
a  yellow  color.  Tenderness  over  right  iliac  fossa.  In  ten 
days  three  of  these  cases  showed  characteristic  rose-colored  spots 
on  abdomen,  one  having  numerous  spots  on  both  extremities; 
one,  also,  had  considerable  enlargement  of  the  spleen. 

In  the  beginning  of  the  third  week  the  temperature  reached 
the  normal  and  all  symptoms  of  fever  declined.  Bowels  be- 
came regular,  headache  disappeared,  tongue  clean,  &c.,  &c. 

These  cases  were  kept  under  observation  for  weeks  after- 
wards to  see  if  any  untoward  symptoms  appeared,  while  at 
the  same  time  they  were  kept  upon  a  liquid  diet.  Four 
weeks  afterwards  they  all  left  the  hospital  fat ;  one  stouter 
than  he  was  previous  to  the  fever. 

The  following  was  a  very  grave  case :  E,.,  set.  22,  entered 
the  hospital  about  the  eighth  day  of  the  disease,  with  very 
high  fever,  pulse  rapid,  120  to  124,  temperature  106°,  P.  M., 
104°,  A.  M.,  appetite  capricious,  tongue  heavily  coated  and 
very  dry.  Bowels  very  loose,  having  as  many  as  twelve 
stools  per  day,  resembling  pea-soup  in  appearance;  his  head- 
ache was  intense ;  ringing  in  the  ears  and  flashes  of  light 
before  the  eyes.  This  condition  of  things  went  on  for  four 
days,  and  then  the  characteristic  eruption  appeared.  In  the 
meantime  his  diarrhoea  had  been  checked  by  the  treatment. 
The  temperature  remained  the  same,  and  his  headache  was 
increasing.  On  the  thirteenth  day,  i.  e.,  from  the  beginning 
of  the  disease,  he  was  suddenly  seized  with  an  active,  wild 
delirium,  which  required  constant  restraint  and  watching,  in 
order  to  prevent  him  from  hurting  himself. 

He  passed  his  urine  and  fteces  in  bed,  unconscious  of  what 
he  was  doing.  His  urine  was  examined  and  found  highly 
colored,  acid  on  reaction,  but  no  albumen.  Two  days  after 
the  setting  in  of  the  delirium  he  became  comatose,  and  died 
shortly  afterwards.  The  temperature  the  last  two  days  was 
105°. 

Autopsy  showed  the  characteristic  lesion  of  Peyer's  patches, 
with  congestion  of  brain  and  lunos. 


General  Diseases.  9 

The  following  seemed  to  be  a  recurrent  attack  of  typhoid 
fever  showing  an  abortive  course :  C.,  set.  25,  had  all  the 
characteristic  symptoms  of  the  fever — diarrhoea,  headache, 
tenderness  in  right  iliac  fossa,  rose-colored  spots  and  high 
temperature.  In  the  latter  part  of  the  fourth  week  the  tem- 
perature began  to  decline,  and  in  five  days  reached  the  normal. 
It  remained  normal  for  ten  days,  and  he  presented  the  condi- 
tion of  one  convalescent  from  typhoid  fever.  Then  the  tem- 
perature began  to  go  up  for  five  days,  until  it  reached  103°, 
p.  M.,  and  remained  stationery  for  six  days,  with  a  slight 
morning  remission.  First,  the  diarrhoea  and  headache  re- 
turned, and  two  days  afterwards  the  eruption  re-appeared. 
After  thirteen  days  of  relapse  the  temperature  went  down, 
and  in  three  days  reached  the  normal.  He  was  very  soon 
convalescent. 

Out  of  thirty  cases,  twenty-one  had  diarrhoea  differing  in 
severity ;  some  having  nine  to  twelve  stools,  others  two  to  five, 
per  diem ;  four,  constipation,  (going  five  days  without  a  pas- 
sage from  their  bowels,)  which  was  quickly  relieved  by  an 
enema.  In  the  remaining  six,  diarrhoea  and  constipation  oc- 
curred alternately.  Sometimes  their  bowels  would  be  regular 
for  four  or  five  days,  and  then  diarrhoea  or  constipation  would 
set  in,  and  so  on  throughout  the  course  of  the  disease. 

The  eruption  appeared  in  twenty-one  cases — the  majority 
showing  it  on  the  abdomen.  It  appeared,  in  a  few  cases,  at 
the  same  time,  on  the  back.  Two  out  of  the  thirty  showed 
spots  on  both  extremities.  The"  number  of  spots  varied;  in 
some  as  many  as  twenty-five  were  counted — in  others  only 
from  two  to  five  could  be  seen.  The  two  having  spots  on  the 
lower  extremities  had  the  largest  number.  Tenderness  in  the 
right  iliac  fossa  was  found  in  a  good  number  of  cases,  but  it 
was  also  absent  where  undoubted  signs  of  typhoid  fever  ex- 
isted. Delirium  showed  itself  in  one-third  of  the  whole 
number  of  cases.  Some  had  very  high  temperatures,  and 
others  had  very  mild  temperatures.  Those  cases  having  very 
high  temperatures,  with  active  deliriuir,  generally  proved 
fatal 


10  Notes  of  Hospital  Practice. 

Three  cases  had  a  temperature  of  106°,  but  had  no  delirium 
during  the  whole  fever. 

Lung  complications  occurred  in  the  majority  of  the  cases,  in  the 
form  of  slight  attacks  of  bronchitis,  or  of  pneumonia,  or  pleu- 
risy— the  former  predominating.  Hemorrhage  from  the 
bowels  occurred  in  one  case,  which  recovered.  As  regards 
the  prognosis,  the  most  unfavorable  signs  were  high  tempera- 
ture, active  and  wild  delirium,  and  severe  diarrhoea.  In  two 
of  the  fatal  cases  there  was  a  very  prominent  symptom — i.  e., 
a  quivering  of  the  extremities  upon  the  slightest  motion. 
When  asked  to  put  out  the  tongue,  it  came  slowly,  tremulous 
and  uncertain.  These  two  patients  were  not  able  to  protrude 
the  tongue  to  its  fullest  extent,  or  when  they  did  so  it  was, 
quickly  retracted,  on  account  of  an  inability  to  keep  it  out. 
Such  manifestations  were  of  unfavorable  omen. 


THE   TREATMENT   OF  TYPHOID   FEVER. 

Dr.  Pepper  regards  the  specific  follicular  catarrh  of  the  in- 
testines as  of  great  importance  in  the  determination  of  the 
treatment.  He  holds  that  there  are  a  number  of  remedies 
which  exert  a  powerful  influence  upon  this  catarrh.  The  first 
of  these  is  the  nitrate  of  silver,  which  reduces  the  size  of  the 
enlarged  follicles,  relieves  the  inflammatory  engorgement,  and 
allays  the  hypersesthesia  of  the  nerves.  So  too  do  carbolic 
acid  and  the  subnitrate  of  bismuth.  He  prefers  the  nitrate  of 
silver,  and  only  substitutes  carbolic  acid  in  its  place  when 
some  putrid  element  is  present.  The  nitrate  of  silver  is  given 
in  quarter-grain  doses,  four  times  daily.  Opium  in  pill 
form  is  combined  with  the  silver  when  the  diarrhoea  is  exces- 
sive. From  one- quarter  of  a  grain  all  the  way  up  to  one  grain 
of  opium  is  given  thrice  or  four  times  daily.  If  the  bowels  are 
constipated,  l>elladonna  is  substituted  in  the  place  of  opium. 

Milk  is  regarded  as  the  best  diet  during  the  stage  of 
catarrhal  inflammation.  The  milk  is  diluted  with  lime-water 
if  the  curd  appears  in  the  stools.  Two  pints  of  milk  and 


General  Diseases.  11 

lime-water,  mixed,  are  given  in  the  course  of  the  twenty-four 
hours. 

The  poisoned  state  of  the  blood  is  controlled  by  means  of 
quinia  and  salicylic  acid.  The  latter  has  been  found  to  be 
very  valuable  in  this  condition  as  a  disinfectant.  Quinia  is 
given  to  the  amount  of  not  more  than  twelve  grains  in  twenty- 
four  hours. 

Temperature  is  kept  down  by  preventive  measures  rather 
than  by  the  cold  bath,  which  is  regarded  as  a  dernier  ressoit. 
When  temperature  runs  up  in  spite  of  drugs,  the  whole  body  is 
sponged  every  two  hours — the  sponges  being  squeezed  out  of 
a  mixture  of  water  and  bay  rum,  at  a  temperature  of  from 
60°  to  80°.  If  the  patient's  temperature  still  runs  up  he  is 
wrapped  in  sheets  wrung  out  of  cold  water.  The  only  case 
in  which  the  cold  bath  is  used  is  in  the  first  ten  days,  where 
the  temperature  rises  above  103°,  and  is  not  to  be  controlled 
by  milder  measures. 

Stimulants  are  not  administered  to  patients  under  the  age 
of  puberty,  as  a  general  thing.  They  are  only  thought  to  be 
demanded  by  some  one  or  more  of  the  following  indications, 
viz. :  (1.)  Ataxic  nervous  disturbances.  (2.)  Profound  as- 
thenia. (3.)  Circulatory  disturbances.  (4.)  Dry  and  brown 
tongue  with  sordes.  The  milder  forms  of  stimulus,  such  as 
wine  whey,  are  always  used  at  first.  When  demanded,  whis- 
key is  given  with  lime-water — the  latter  being  added  to  pre- 
vent coagulation — in  the  proportion  of  f  1  ss.  each  of  whie- 
key  and  lime-water  to  every  f  |  iij.  of  milk. 

Relapses  are  treated  as  first  attacks.  Hemorrhage  is  man- 
aged by  absolute  rest  in  bed  for  twenty-four  hours,  and  by 
the  administration  of  opium  to  produce  absolute  rest  for  thtj 
alimentary  canal.  Acetate  of  lead  is  sometimes  combined 
with  the  opium  in  the  shape  of  suppositories.  Ergot  is  also 
very  useful.  The  food  allowed  is  small  in  quantity  and  liquid, 

Dr.  Cohen  finds  that  large  doses  of  quinia  rather  increase 
the  diarrhoea  and  headache.  His  patients  are  sponged  with 
vinegar  and  water,  and  abundant  ice  is  given  them  to  suck. 


12  Notes  of  Hospital  Practice. 

Oil  of  turpentine  in  20  gtt.  doses  every  hour  or  two  in  mucil- 
age, he  has  found  to  act  most  beneficially.  Morphia  is  given 
hypodermically  iu  half-grain  doses  where  the  delirium  ia 
•ictive. 

Dr.  William  H.  Bennett  reduces  the  temperature  and 
strengthens  the  heart  by  10  gtt.  doses  of  digitalis  thrice  daily. 

Dr.  Louis  Starr  controls  diarrhoea  by  starch  and  laudenum 
enemata. 

PLEURO-PNEUMONIA  FOLLOWING  TYPHOID  FEVER — DEATH 
FROM  LARGE  PLEURITIC  EFFUSION  AT  END  OF  SEVENTH 
WEEK,  WITH  PEYER'S  PATCHES  STILL  UNHEALED. 

George  Ross,  set.  26,  born  in  Massachusetts,  a  sailor,  single ; 
admitted  October  30th,  1877 ;  always  enjoyed  good  health^ 
and  denies  venereal  disease ;  had  been  sick  four  weeks  at  sea 
before  admission,  the  principal  symptoms  being  prostration 
and  some  fever.  He  was  in  a  condition  of  slight  hebetude 
when  admitted.  It  was  difficult  to  obtain  much  history,  but 
the  captain  of  his  ship  stated  that  there  had  been  no  diarrhoea, 
epistaxis,  or  actual  delirium.  Respiration  was  slightly  jerk- 
ing, but  the  lungs  expanded  well  and  no  abnormal  sounds 
could  be  detected  in  the  chest.  He  had  no  cough  ;  the  abdo- 
men was  not  tympanitic,  and  the  marks  of  some  kind  of  plas- 
ter were  noticed  in  the  hypogastric  and  iliac  regions. 

Temperature  upon  admission  was  101°,  the  pulse  101,  and 
the  respirations  24  to  the  minute.  The  patient  was  restless 
and  irritable  and  required  watching  at  night,  although  there 
was  no  marked  delirium.  He  seemed  rather  dull  and  did  not 
complain  of  anything.  Bowels  were  moved  two  or  three 
times  daily  after  admission.  The  urine  was  light  colored, 
cloudy,  sp.  gr.  1010,  no  albumen  and  no  sugar. 

November  2d. — Patient  found  to  have  left-sided  pneumonia; 
dullness  at  left  base  posteriorily,  where  there  is  also  impaired 
respiration,  coarse  crepitation,  with  bronchophony  and  bron- 
chial breathing  above  and  whiffling  in  respiration  at  line  of 
dullness.  These  signs  were  not  found  in  the  front,  where  the 


General  Diseases.  13 

percussion  note  was  clear  on  both  sides,  and  the  respiration 
vesicular.  There  was  no  cough  and  no  expectoration. 

The  nails  showed  checking  of  growth  in  a  ridge  running 
across  the  nail  at  about  one-third  the  distance  from  the  mat- 
rix to  the  free  border.  He  was  ordered  turpentine  stupes, 
quiuia  (gr.  xij)  daily,  and  a  mixture  containing  gtt.  v  of  the 
tincture  of  digitalis  and  gr.  x  of  the  citrate  of  potassium  every 
four  hours.  The  impulse  of  the  heart  was  moderately  ex- 
tended, but  not  forcible.  The  first  sound  was  murmurish  and 
soft,  but  there  was  no  murmur. 

November  3d. — Physical  characters  much  the  same;  still 
no  cough.  There  is  impaired  breathing,  and  some  fine 
rales  can  be  heard  at  the  right  base  posteriorly,  with  some 
loss  of  resonance.  The  dullness  on  the  left  side  is  clearing 
up;  the  respiration  anteriorly  is  rather  exaggerated;  th*» 
amount  of  whiskey  increased  to  f  §  vj  daily. 

November  bth. — Decided  dullness  at  right  base  posteriorly, 
with  signs  of  pneumonic  consolidation  of  lower  half  of  lung. 
The  left  side  is  clearing.  Ordered  carbonate  of  ammonia  (gr. 
x)  every  three  hours. 

November  7th. — Considerable  dullness  of  right  side  ante- 
riorly ;  is  troubled  with  hiccough  upon  the  slightest  exertion ; 
this  continues  nearly  all  night;  has  a  slight  cough  occasion- 
ally ;  he  is  restless  at  night. 

Treatment  continued ;  blister  to  right  chest  anteriorly ; 
spirits  of  chloroform  (f3j)  administered  four  times  a  day; 
takes  ten  ounces  of  whiskey  daily;  tongue  coated  and  dry  ;  no 
cardiac  murmur ;  a  little  faint  crepitation  at  base  of  heart,  but 
the  patient's  condition  prevents  him  from  holding  his  breath 
for  the  purpose  of  accurate  diagnosis. 

November  8th. — Tongue  tremulous ;  has  a  little  dry  cough 
and  troublesome  singultus.  Ordered  plenty  of  milk,  beef- 
tea,  eggs,  &c. 

November  9th. — Looks  better,  but  still  very  weak ;  still 
considerable  dullness  over  the  upper  part  of  the  right  lung, 
where  respiration  is  imperfect  and  feeble,  with  slightly  pro- 


14  Notes  of  Hospital  Pradics.. 

longed  expiration.  The  whole  condition  seems  to  give  the 
idea  of  non-expansion  or  of  collapse.  The  pulse  has  better 
volume;  tongue  cleaner,  moister  and  slightly  coated,  but  is 
less  typhoidal  in  its  appearance.  There  is  less  hebetude. 

November  11th. — Hiccough  better;  still  taking  ten  ounces 
of  whiskey  daily,  and  carbonate  of  ammonia  every  two  hours ; 
respiration  rather  feeble  at  the  right  base,  with  coarse  crack- 
ling above  it ;  tongue  rather  dry,  with  white  coating,  but  less 
dry  than  before ;  no  albuminuria.  Basham's  mixture  (f.  |  ss.  s. 
t.  d.)  now  ordered.  There  is  some  effusion  at  the  right  base. 

November  12th. — Twitching  of  the  facial  muscles  in  sleep; 
respirations  23  in  sleep  and  36  awake ;  has  very  little  hiccough 
at  present. 

November  13th. — Better  to-day  than  yesterday ;  appearance 
brighter;  urine  normal;  pulse  has  rather  more  volume;  there 
is  a  sound  of  friction  at  the  right  base. 

November  14th. — About  the  same ;  temperature  rather  high  ; 
respiration  quite  feeble,  with  some  prolongation  of  respiratory 
murmur  at  the  right  apex,  with  still  some  dullness;  fremitus 
on  right  side  feeble ;  the  evidence  of  effusion  at  the  right  base 
persists.  Whiskey  increased  to  f.  i  viij,  and  Basham's  mixture 
given  four  times  daily ;  quinia,  gr.  xvj,  daily,  and  carbonate 
of  ammonia,  gr.  x,  every  four  hours. 

November  15th. — Impulse  at  apex  of  heart  is  not  in  the 
normal  position,  but  is  a  little  outside  of  the  linea  mammalis ; 
the  sounds  are  indistinct,  yet  well  defined ;  the  heart  is  dis- 
placed by  pressure  from  the  right  side,  but  its  beat  is  distinctly 
felt ;  the  lower  part  of  the  right  lung  moves  a  little  in  respi- 
ration. Ammoniae  carb.  to  be  stopped,  and  Basham's  mixture 
to  be  given  every  three  hours. 

November  18th. — Is  passing  water  freely ;  apparently  im- 
proving ;  respiration,  though  feeble  at  the  lower  part  of  the 
right  lung,  is  again  distinctly  vesicular  and  is  less  dull,  but 
there  is  still  impaired  resonance  at  the  right  apex ;  the  apex 
beat  of  the  heart  retains  its  distinctness,  and  is  seen  as  well  as 
felt  \u  the  sixth  intercostal  space,  one  and  one-half  inches  to 


General  Diseases.  15 

the  outside  of  the  nipple;  a  slight  quiver  can  be  seen  in  the 
space  above  ;  there  is  slight  friction  at  the  left  base ;  respira- 
tion well  sustained  on  the  left  side,  low  down,  but  it  is  rather 
harsh. 

Died  this  afternoon. 

A  post-mwtem  examination  reveals  an  immense  effusion  in 
the  right  chest,  with  condensation  of  lung  by  pressure ;  heart 
pushed  to  left ;  no  active  sign  of  pneumonia. 

In  the  ileum  were  found  patches  of  Peyer  in  an  ulcerated 
condition,  one  having  sloughed  out,  leaving  the  sub-mucous 
coat  with  a  healthy,  granulating  surface. — Dr.  DaCosta. 

INDICATIONS   AGAINST   PARACENTESIS   THORACI8. 

The  case  had  been  in  the  wards  for  some  time,  with  the 
history  of  an  attack  of  pleurisy  following  exposure.  When? 
the  patient  was  first  admitted  in  November,  examination 
revealed  an  old  right-sided  pleurisy,  with  some  evidence  of 
abscess  of  the  right  lung.  Subsequently  the  signs  of  pleuritic 
effusion  developed  rapidly,  and  it  was  very  evident  that  there 
was  considerable  effusion  in  the  lower  part  of  the  chest. 

The  question  which  arose  was  whether,  with  the  evidence 
of  a  right-sided  pleurisy,  which  remained  rather  stationary, 
together  with  the  suspicion  of  tuberculous  disease,  resort  should 
be  had  to  aspiration,  or  whether  the  endeavor  should  be  made 
to  get  rid  of  the  effusion  by  medicinal  means.  When  the 
patient  was  first  admitted  he  had  already  had  the  effusion  for 
several  months. 

Upon  thinking  the  case  over,  and  considering  the  strong 
probability  of  disease  of  the  lung  itself,  though  marked ;  find- 
ing also  no  marked  irritative  fever,  and  having,  therefore,  no 
reason  to  suppose  that  the  chest  was  full  of  pus,  Dr.  DaCosta 
concluded  to  try  and  get  rid  of  the  effused  serum  by  medicinal 
means,  and  determined  not  to  tap  the  chest.  The  result  ju^t* 
fied  the  conclusion  reached. 

On  February  1st  the  dullness  still  remained  low  down  in 


16  Notes  of  Hospital  Practice. 

the  right  chest.  The  voice  was  transmitted  from  all  other 
parts  of  the  lung.  So,  too,  with  regard  to  the  vocal  fremitus. 
The  breathing  was  also  fuller  and  deeper. 

The  treatment  consisted  principally  in  the  administration 
of  the  tincture  of  the  chloride  of  iron,  with  acetate  of  ammo- 
nium. Occasionally  a  Dover's  powder  was  given  at  bedtime. 
The  food  was  generous,  and  counter-irritation  was  frequently 
made  with  iodine  or  blisters. 

From  the  good  results  already  shown,  Dr.  DaCosta  was 
confident  that  this  treatment  ought  to  be  persevered  in. 

The  patient  was  ordered  in  future  a  tablespoon  ful  of  Basham's 
mixture  four  times  daily,  and  a  tablespoonful  of  cod-liver  oil 
thrice  daily,  on  account  of  the  suspected  latent  disease  of  the 
lungs. 

The  case  was  regarded  as  proving  that  it  is  never  wrong  in 
old  cases  of  pleural  effusion  to  give  a  fair  trial  to  medicinal 
means  first,  and  never  to  try  tapping  until  we  are  quite  sure 
that  all  other  modes  of  relief  are  of  no  avail. 

The  three  points  particularly  suggested  and  emphasized  by 
the  case  were — (1)  that  we  should  be  guided  rather  by  the 
effects  of  an  effusion  than  by  the  time  it  has  lasted;  (2)  the 
value  of  Basham's  mixture  and  repeated  counter-irritation  in 
the  treatment  of  chronic  pleurisy ;  (3)  the  possibility  of  tuber- 
culous disease  of  the  lung  as  a  co-existent  factor  is  always  an 
additional  reason  for  not  tapping,  since  surgical  interference 
should  never  be  attempted  when  this  complication  exists. 

PNEUMONIA. 

The  routine  treatment  of  pneumonia  in  the  wards  of  the 
Pennsylvania  Hospital  consists  in  the  internal  administration 
of  from  eight  to  twelve  grains  of  quinia  daily,  together  with  a 
moderate  amount  of  nitrate  of  potassium  and  of  the  tincture  of 
digitalis  every  two  or  three  hours.  Plenty  of  stimulus  is  ad- 
ministered. In  a  case  recently  under  treatment,  Dr.  DaCosta 
gave  in  place  of  the  nitrate  of  potassium  a  teaspoonful  of  the 


General  Diseases.  17 

jpirits  of  ammonia  in  water  every  three  hours,  as  an  alkali. 
This  use  of  ammonia  (as  an  alkali)  was  so  successful  in  Dr. 
DaCosta's  hands  that  Dr.  Hutchinson  tried  it  in  one  of  his 
eases  with  equally  good  results. 

THE   TREATMENT   OF  ORGANIC   HEART   DISEASE. 

In  those  instances  where  there  is  a  maximum  amount  of 
cardiac  force,  with  a  minimum  amount  of  valvular  lesion, 
cardiac  sedatives  are  regarded  by  Dr.  Pepper  as  the  remedies 
par  excellence.  Veratrum  viride,  aconite,  the  bromide  of 
potassium,  and  other  bromides  are  given  in  small  and  con- 
tinued doses.  The  need  of  cardiac  sedatives  has  been  found 
to  be  most  marked  in  diseases  of  the  mitral  valve,  where  there 
is  a  marked  tendency  to  hypertrophy  of  the  left  ventricle; 

In  these  cases  the  diet  allowed  is  cooling  and  restricted ;  cir- 
culatory and  nervous  stimulants  are  avoided.  If  the  general 
system  is  plethoric  a  saline  depurative  is  administered.  The 
diet,  though  restricted,  is  not  reducing,  i.  e.,  the  blood  is  not 
reduced  in  quality  by  it,  though  it  is  of  such  a  kind  as  to  be 
easily  digested. 

Where  the  valvular  lesion  has  been  the  result  of  an  endo- 
carditis contracted  in  early  life,  it  has  often  been  found  possi- 
ble to  accomplish  the  greatest  amount  of  good  by  continuous 
doses  of  the  iodide  of  potassium.  This  treatment  has  often 
cured  young  children  with  hypertrophied  left  ventricles  and 
mitral  disease. 

In  those  cases  of  heart  disease  showing  impairment  of  power, 
and  occurring  late  in  life,  the  most  important  item  of  treat- 
ment is  rest  and  the  avoidance  of  all  muscular  effort.  Such 
patients  are  given  beds  on  the  ground  floor  and  never  allowed 
to  mount  stairs.  In  bad  cases  rest  upon  one  floor  and  in  one 
room  is  insisted  upon. 

The  question  of  diet  in  the  treatment  of  heart  disease  has 
received  unusual  attention  in  the  Hospital  of  the  University  of 
Pennsylvania.  The  diet  is  studied  in  connection  with  the  state  of 


18  Notes   of  Hospital  Practice. 

the  system.  When  the  digestion  is  good  and  the  blood  not  in 
abundance,  the  patient  is  allowed  bread,  meat,  fruits,  and  green 
vegetables  quite  freely.  Some  such  patients  have  been  bene- 
fited by  a  lean  meat  diet.  No  patient  in  this  condition  can 
digest  oil  well.  In  those  cases  where  the  digestion  is  not 
good,  koumyss,  buttermilk,  or  skimmed  milk  is  given.  Where 
the  secretions  are  scanty  and  dropsy  is  present,  the  diet  pre- 
scribed is  exclusively  one  of  milk.  Such  patients  are  not 
allowed  to  eat  much  at  a  time,  but  take  food  frequently  and 
in  small  quantities. 

Where  spasms  of  cough  and  of  dyspnoea  occur  at  night,  the 
patient  is  only  given  a  small  amount  of  stimulus  and  liquid 
nourishment  for  some  hours  before  going  to  bed. 

(To  return  for  a  moment  to  the  question  of  rest.  In  some 
mild  cases  of  heart  disease,  gentle,  moderate  walking  is 
strongly  advised,  but  in  no  instance  is  needless  running  hither 
and  thither  allowed.) 

For  the  relief  of  the  various  congestions  consequent  upon 
heart  disease,  counter-irritants  are  applied  over  the  affected 
part.  Where  nervous  and  head  symptoms  predominate,  dry 
cups  are  applied  to  the  nape  of  the  neck.  In  pulmonary  con- 
gestion, muriate  of  ammonia  is  given  internally  in  addition  to 
the  external  counter-irritation.  The  bromides  are  used  in 
cerebral  congestions.  When  the  stomach  is  congested,  blue 
mass  is  prescribed. 

When  the  appetite  is  poor,  the  stools  insufficient,  the  liver 
tender  upon  palpation,  and  the  secretions  of  the  intestines 
scanty,  blue  pills,  followed  by  a  saline  laxative,  is  a  favorite 
remedy.  Renal  congestion  is  put  a  stop  to  by  digitalis,  to- 
gether with  a  saline  diuretic. 

When  the  system  is  in  an  ansemic  state,  when  the  blood  is 
watery,  and  when  it  is  deficient  in  red  globules,  iron  is  given 
with  advantage.  Active  plethora  is  always  regarded  as  a 
counter-indication  to  the  use  of  iron.  The  iron,  when  given, 
is  administered  in  the  form  of  a  laxative  ferruginous  water, 
or  a  diuretic  ferruginous  mineral  water. 


General  Diseases.  19 

In  the  treatment  of  the  various  dropsies  complicating  heart 
disease,  cups,  blisters,  iodine  painted  on  the  surface,  or  iodine 
with  croton  oil  is  used. 

In  some  cases  the  dropsy  is  entirely  cured  by  rest  and  a 
skimmed-milk  diet. 

In  cases  of  anasarca  the  most  rapid  relief  is  obtained  by  the 
use  of  jaborandi.  Where  the  heart  is  so  weak  that  jaborandi 
cannot  be  used,  resort  is  had  to  laxatives,  or  warm  vapor 
baths. 

Ascites  is  met  by  saline  diuretics  ;  hydrothorax  by  diaphor- 
etics and  diuretics.  The  patient's  whole  body  is  periodically 
examined  physically,  to  see  that  no  effusion  is  gaining  head- 
way. 

If  the  dropsy  becomes  otherwise  unmanageable,  resort  is 
had  to  operative  measures,  and  the  skin  is  tapped — a  number 
of  minute  punctures  being  made  in  the  skin  with  delicate 
needles. 

Where  there  is  a  faulty  condition  of  the  nervous  ganglia  of 
the  heart,  associated  with  the  organic  disease,  digitalis  is  em- 
ployed with  great  benefit.  Where  one  preparation  of  this 
drug  is  not  borne  by  the  stomach,  another  is  substituted. 
Where  the  separate  contractions  of  the  heart  are  evidently 
inefficient,  and  the  pulse  is  weak  and  small,  digitalis  has 
proved  itself  an  unrivaled  remedy.  The  usual  dose  of  the 
tincture  is  gtt.  x;  of  the  infusion,  f  3j  ;  and  of  digitalra,  gr, 
J/60  every  three  hours. 

Belladonna  has  been  of  service  where  the  heart's  action  is 
strong  but  irregular.  Where  the  heart  muscles  are  weak  and 
passive  congestions  rife,  strychnia  and  quinia  are  prescribed. 

ALBUMINOID   DEGENERATION   OF  THE   KIDNEYS   OF  PROBA- 
BLE   SYPHILITIC    ORIGIN,    WITH     OZ^NA    AND     PSEUDO- 


MEMBRANOUS   ANGINA. 


The  patient  was  a  white  man,  thirty  years  of  age.     When 
admitted  to  the  hospital  he  presented  the  following  history- 


20  Notes  of  Hospital  Practice. 

He  had  been  engaged  in  the  manufacture  of  morocco  for  tlu 
past  fourteen  years,  with  the  exception  of  three  years  spent  in 
a  butcher's  shop.  His  habits  had  been  good,  always,  except 
when  butchering,  when  he  was  intemperate.  He  had  always 
been  a  hard-working  man,  and  had  been  constantly  exposed 
to  coid  and  wet.  He  had  variola  and  measles  Avhen  a  child, 
but  no  other  exanthematous  disease.  He  was  a  married  man, 
and  had  one  child,  who  suffered  constantly  from  oedema  of 
the  feet,  and  face.  His  (the  patient's)  father  died  of  paralysis 
of  syphilitic  origin,  and  his  mother  of  dropsy.  His  only 
living  brother  was  healthy,  but  his  sister  had  goitre,  palpita- 
tion and  dropsy. 

During  the  twelve  months  prior  to  his  admission  the  patient 
had  had  frequent  pains  in  the  back  and  frequent  dyspnoea. 
During  the  last  four  months  of  this  time  there  had  been  a 
general  condition  of  anasarca. 

The  appearances  presented  by  the  man  upon  admission 
were  as  follows:  His  face,  neck,  feet  and  body  were  swol- 
len. His  general  aspect  was  markedly  anemic.  He  was  de- 
cidedly drowsy,  but  his  intellect  was  good.  His  tongue  was 
tremulous,  coated,  and  flabby,  and  there  was  a  membranous 
patch  upon  his  uvula.  The  tonsils  were  enlarged,  and  the 
throat  sore.  The  man's  appetite  was  good,  but  there  was 
considerable  flatulence  and  pyrosis  after  meals.  His  bowels 
were  somewhat  costive.  Respiration  was  attended  with  a 
loud  noise  in  the  larynx.  Expiration  was  prolonged.  The 
glands  on  the  right  side  of  the  neck  were  swollen.  He  had  a 
bad  taste  in  his  mouth,  and  his  breath  had  an  unpleasant 
Bmell.  There  was  no  abdominal  effusion,  and  his  lungs 
seemed  to  be  healthy.  The  sounds  of  the  heart  were  distant 
and  feeble,  and  the  pulse  was  small  and  rapid.  The  apex- 
beat  of  the  heart  could  be  felt  underneath  the  rib  in  the  fourth 
interspace ;  a  weak  impulse  could  also  be  felt  in  the  second 
and  third  interspaces  at  the  border  of  the  sternum.  The 
upper  border  of  cardiac  dullness  was  a  line  drawn  from  the 
head  of  the  second  rib  to  the  left  nipple,  and  its  utmost  limit 


General  Diseases.  21 

outwards  was  a  line  drawn  directly  downwards  from  the  nip- 
ple to  the  fifth  rib.  A  line  drawn  parallel  to  the  linea  mam- 
mal is  and  running  from  the  fifth  rib  to  the  xiphoid  cartilage 
represented  the  lower  border  of  cardiac  dullness,  while  its  limit 
on  the  right  was  the  median  line  of  the  sternum.  The  urine 
passed  was  dark  red  in  color,  and  of  alkaline  reaction,  and 
amounted  to  sixty-four  ounces  in  the  course  of  twenty-four 
hours.  The  contained  albumen  formed  fully  one-half  its 
bulk.  Its  specific  gravity  was  1006.  It  contained  many 
granular  and  hyaline  casts. 

Dr.  Pepper  regarded  the  case  as  one  of  a  very  curious  and 
interesting  nature.  It  was  concluded  that  the  kidneys  were 
the  seat  of  albuminoid  degeneration,  with  catarrhal  nephritis. 
The  underlying  constitutional  taint  seemed  to  be  undoubtedly 
syphilitic.  It  was  argued  that  the  angina  was  an  outcome  of 
the  systemic  disease,  but  that  the  ozsena  was  presumably  a 
manifestation  of  the  catarrhal  nephritis. 

The  case  was  regarded  as  an  excel  lent  example  of  those  cases 
of  hereditary  syphilitic  infection  in  which  the  poison  is  so  diluted 
and  the  patient's  constitution  so  robust  that  the  disease  does 
not  show  itself  until  well  on  towards  middle  life. 

The  indications  for  treatment  were  thought  to  consist  in  (1) 
the  removal  of  the  dropsy  by  large  doses  of  jaborandi,  and  (2) 
in  a  nourishing  and  easily  digestible  diet.  Buttermilk,  oat- 
meal gruel,  and  light  broths  were  ordered  as  foods. 

After  the  dropsy  had  largely  disappeared  minute  doses  of 
the  bichloride  of  mercury,  with  the  iodide  of  potassium,  were 
administered ;  at  the  same  time  cod-liver  oil  was  given  in 
combination  with  the  iodide  of  iron.  The  patient  was  much 
improved. 

IDIOPATHIC  PERITONITIS. 

If  the  case  is  brought  into  the  wards  at  the  very  inception 
of  the  disease,  the  patient  is  bled  thoroughly  from  the  arm. 
If  the  disease  is  of  many  hours  standing,  Dr.  Wood  has  the 


22  Notes  oj  Hospital  Practice. 

abdomen  covered  with  as  many  leeches  as  it  will  hold.  After 
venesection,  calomel  is  administered  in  doses  of  from  one- 
quarter  to  one-half  of  a  grain  every  hour.  In  connection 
with  the  calomel,  opium  is  given  in  large  doses.  Opium  in- 
duces quiet  and  prevents  the  exhaustion  consequent  upon  hor- 
rible physical  pain.  Enough  opium  is  given  to  keep  the 
patient  on  the  verge  of  narcotism.  It  had  better  be  given  in 
liquid  form. 

In  the  latter  stages  of  peritonitis,  blisters  are  always  em- 
ployed. 

The  first  thing  done,  however,  when  the  leeches  have  been 
removed,  is  to  apply  poultices ;  whether  they  be  hot  or  cold 
makes  but  very  little  difference.  Where  there  is  a  very 
marked  tendency  to  feverishness,  cold  poultices  are  used.  If 
the  abdomen  is  too  tender  to  bear  the  weight  of  the  ice-bag, 
light  flannel  cloths  wrung  out  of  ice-water  may  be  used.  On 
the  other  hand,  a  warm-water  dressing  may  be  employed  with 
advantage  in  very  many  cases.  Warm  water  acts  not  only  as  a 
local  derivative,  but  some  of  it  probably  oozes  through  the 
intervening  tissues  into  the  abdomen,  and  so  acts  directly  upon 
the  inflamed  peritoneum  as  a  soothing  agent. 

After  the  abdomen  has  been  thoroughly  poulticed  for  two 
or  three  days,  blisters  are  used,  provided  the  temperature  of 
the  body  has  not  remained  high.  The  blister  should  not  be 
a  small  one — eight  inches  by  ten  makes  a  very  good  size. 

When  there  is  any  septic  element  in  the  disease,  quinia  is 
used  with  great  benefit.  Generally  the  stomach  is  not  strong 
enough  to  bear  it. 

The  patient  must  have  but  very  little  food  in  the  first  few 
days  of  the  attack.  The  food  which  is  given  is  that  which 
leaves  the  least  residuum  of  undigested  matters,  and  therefore 
causes  the  least  amount  of  peristaltic  action  on  the  part  of  the 
intestines.  Milk,  in  repeated  small  doses,  is  the  food  usually 
given.  At  the  end  of  a  few  days,  solid  articles  are  allowed. 
When  there  are  symptoms  of  exhaustion  late  in  the  course  of 
the  attack,  beef-tea  is  given  as  a  stimulant.  Alcohol  is  not 


General  Diseases.  23 

only  powerless,  but  even  dangerous  in  the  early  stages  of  the 
disease.  A  few  doses  of  brandy  in  the  first  few  days  of  an 
attack  of  peritonitis  may  produce  death. 

With  regard  to  the  opening  of  the  bowels  during  conval- 
escence, a  purgative  or  an  enema  is  never  used.  These  bring 
violently  into  play  all  the  muscles  of  the  abdomen.  Very 
often  there  will  be  a  spontaneous  movement  on  the  fifth  or 
sixth  day  without  any  medicine  at  all.  If  there  is  not  such  an 
opening,  a  small  dose  of  castor  oil  is  given  at  the  end  of  ten 
days.  If  there  is  retention  of  urine,  the  water  is,  of  course, 
drawn  off  by  means  of  the  catheter. 

Great  care  is  had  during  convalescence  from  peritonitis  to 
prevent  a  relapse.  No  violent  or  gymnastic  exercise  is  al- 
lowed for  a  long  time  afterward. 

TWO   INTERESTING   CASES  OF   VOMITING. 

CASE  I, — eet.  twenty-five.  Family  history  not  good. 
Sister  and  father  both  died  of  phthisis.  She  herself  was 
always  healthy.  Began  to  menstruate  at  age  of  seventeen  and 
stopped  menstruating  at  twenty.  Since  then  the  menses  have 
been  very  irregular.  She  married  at  the  age  of  eighteen  and 
was  a  widow  at  twenty-one.  You  will,  therefore,  notice  that 
the  irregularity  of  menstruation  has  existed  not  only  during 
marriage,  but  also  before  and  since. 

She  comes  into  the  hospital  for  the  treatment  of  what  is 
apparently  a  very  serious  difficulty,  viz.,  she  has  been  vomit- 
ing constantly  for  nearly  a  year.  She  has  been  in  the  hos- 
pital for  only  a  week.  She  has  been  vomiting  incessantly  ; 
has  never  retained  more  than  one  meal  during  the  course  of 
the  day  for  the  past  year.  The  vomiting  always  begins  the 
instant  after  her  meal  is  over.  She  does  not  have  much 
vomiting  or  nausea  between  her  meals. 

A  year  ago  she  was  stout  and  healthy,  but  the  vomiting 
has  rendered  her  thin  and  pale.  Though  not  so  this  morn- 
ing, it  is  fair  to  state  that  she  has  picked  up  wonderfully 


24  Notes  of  Hospital  Practice. 

within  the  last  few  days,  and  you  will,  no  doubt,  want  to 
know  what  has  been  done. 

-  In  the  first  place,  I  had  the  vomited  matter  examined, 
with  but  negative  results.  There  were  no  sarcinse,  nothing 
but  mucous  mixed  with  the  contents  of  the  stomach.  Occa- 
sionally the  patient  has  been  disturbed  by  vomiting  mucous 
iu  her  sleep. 

Together  with  the  vomiting  you  notice  that  she  has  a  slight, 
irritative  cough.  This  cough  has  troubled  her  ever  since  the  vom- 
iting began.  Joined  with  the  cough  there  is  no  expectoration. 

Before  going  any  further,  however,  I  will  examine  the  gas- 
tric and  intestinal  organs.  Her  tongue  is  slightly  coated  and 
.flabby,  and  there  is  some  tenderness  in  the  epigastric  region 
and  along  the  spine,  particularly  at  about  the  middle  point  of 
the  spine.  There  is,  however,  no  appearance  of  a  tumor. 
The  soreness  in  the  epigastrium  is  general,  and  is  not  local- 
ized in  particutar  spots.  The  bowels  are  constipated ;  the 
respiratory  sounds  are  normal.  There  is  no  albumen  or  abnor- 
mal ingredient  in  the  urine.  There  is  no  fever,  and  the 
temperature  is  normal.  The  urine  is  acid  and  of  the  usual 
color,  with  a  specific  gravity  of  1025. 

What  has  been  the  cause  of  vomiting?  What  remedy  is  it 
which  has  stopped  the  vomiting  in  three  days  ? 

When  I  first  saw  the  woman  in  the  wards  and  heard  of  the 
incessant  vomiting,  I  first  thought  it  was  a  case  of  irritable 
stomach  in  a  young  woman,  connected  with  gastric  ulcer.  The 
epigastric  soreness,  the  age  of  the  patient,  the  appearance  of 
the  tongue,  the  disordered  menstruation,  the  sore  point  in  the 
spine,  all  tended  in  that  direction. 

I  soon  gave  up  the  idea,  however.  Gastric  ulcer  gives  rise 
to  local  soreness;  here  the  soreness  was  general.  Gastric 
ulcer  is  attended  by  hemorrhage  and  pain  upon  taking  food, 
which  was  not  the  case  here.  The  two  most  prominent  symp- 
toms of  ulceration  were  absent.  I  rejected  the  idea. 

Then  there  came  up  a  point  of  experience  in  my  mind — 
one  case  similar  had  happened  not  long  since  in  my  own  prac- 


General  Diseases.  25 

tice ;  several  I  had  seen  in  consultation.  In  one  case  the 
vomiting  had  reduced  the  patient  almost  to  the  verge  of  the 
grave;  nothing  stayed  on  her  stomach.  In  her  case  the  irrita- 
tion was  reflected  upon  the  stomach  from  a  uterine  malady — a 
slight  flexion.  It  was  not  very  different  from  the  sympathetic 
vomiting  of  pregnancy.  Moreover,  there  was  in  that  case  a 
certain  amount  of  gastric  disease — a  catarrhal  affection  of  the 
stomach  came  on  as  a  complication  of  the  nervous  affection. 
In  the  light  of  that  experience  I  began  to  suspect  the  same 
condition  here.  As  a  result  of  examination  we  found  retro- 
flexion  of  the  uterus.  The  whole  case  was  cleared  up  at 
once.  It  was  reflex  vomiting  with  a  certain  amount  of  gas- 
tric catarrh,  lasting  for  a  year,  although  the  woman  had 
taken  the  greatest  care  with  her  diet,  etc. 

When  she  was  first  admitted  she  was  put  upon  lime-water 
and  milk,  but  there  was  no  effect  produced  upon  the  vomit- 
ing. How  did  we  check  it?  It  was  not  by  diet  alone. 

Again  experience  came  to  my  assistance,  and  I  determined 
to  try  the  application  of  ice  to  the  spine  as  a  systematic  treat- 
ment, every  few  hours.  The  ice  was  applied  and  left  on 
until  it  chilled  the  patient  and  made  her  skin  cold.  The 
application  was  often  repeated — as  often  as  she  could  bear  it. 
Its  effects  were  admirable.  No  other  treatment  was  neces- 
sary. The  vomiting  stopped  almost  at  once. 

You  will  not  always  be  so  successful  with  this  remedy 
alone.  Is  there  nothing  which  we  can  combine  with  the  ice — 
must  we  depend  upon  it  alone?  By  no  means.  Bromide  of 
sodium  in  doses  of  ten  or  fifteen  grains  thrice  daily  is  very 
effectual.  It  lessens  the  reflex  irritation,  and  is  not  rejected 
by  the  stomach.  An  occasional  purge  by  an  enema,  or  some 
bitter-water,  is  often  desirable.  Subsequently,  if  the  case 
lingers,  use  blisters  to  the  spine.  Do  all  this  irrespective  of 
the  local  uterine  treatment,  for  the  reduction  of  the  uterine 
displacement  will  not  always  stop  the  vomiting  at  once — the 
cause  is  removed,  but  not  the  habit. 

To-day  I  shall  introduce  a  pessary.     Already  the  girl's 


26  Notes  of  Hospital  Practice. 

diet  has  been  increased,  and  she  is  beginning  to  retain  solid 
food. 

What  else  can  we  use  in  such  cases  to  soothe  the  stomach  ? 
Pepsin  is  very  valuable  as  soon  as  the  vomiting  has  been 
stopped.  The  dose  of  saccharated  pepsin  is  five  grains  thrice 
daily.  The  diet  all  this  while  should  be  gradually  increased  ; 
only  small  quantities  of  food  being  given,  but  these  fre- 
quently. 

This  condition  is  very  similar  to  hysterical  vomiting. 
There  is  no  manifestation  of  hysteria  here.  The  two  states  are 
parallel,  but  not  identical.  In  an  hysterical  case  the  results 
of  treatment  would  not  be  so  good. 

CASE  II, — set.  fifty-five,  single,  comes  of  healthy  family. 
Her  own  health  has  not  been  bad  considering  her  age  and 
occupation — that  of  cook.  She  has  suffered  from  dyspepsia 
for  a  long  time,  together  with  flatulence  and  constipation. 
She  is  also  a  sufferer  from  sick  headache,  and  from  a  certain 
amount  of  pain  in  her  stomach. 

Some  time  after  these  symptoms  appeared,  her  abdomen 
began  to  swell  and  became  painful.  She  vomited ;  on  two 
occasions  vomited  blood.  Her  general  health  at  the  same 
time  has  failed,  and  she  has  lost  flesh,  and  is,  as  you  see,  very 
pale  and  anemic.  This  morning  she  vomited  blood  for  the 
third  time. 

The  treatment  shall  be  based  (1)  upon  the  haematemesis, 
and  (2)  upon  the  general  gastric  symptoms.  Since  she  has 
taen  in  the  hospital  she  has  vomited  every  day.  Attending 
this  vomiting  there  has  been  a  burning  pain  in  her  stomach. 
This  pain  is  not  always  increased  by  taking  food,  and  often 
existed  apart  from  the  hours  of  her  meals. 

The  vomit,  a  specimen  of  which  I  here  show  you,  consists 
of  black  coagula — coffee-grounds — the  usual  character  of  the 
vomit  of  cases  of  haematemesis.  The  attack  of  vomiting 
which  she  had  this  morning  has  rendered  her  pale  and  weak. 

The  disease  is  plainly  shown,  by  the  character  of  the  vomit, 
to  bf  situated  in  the  stomach ;  is  probably  gastric  ulcer. 


General  Diseases.  27 

Her  temperature  has  risen  to  100°,  her  pulse  is  feeble  and 
compressible,  there  is  general  soreness  over  the  epigastric 
region,  the  tongue  is  dry  and  but  slightly  coated.  The 
woman  is  scarcely  in  a  condition  for  me  to  attempt  an  accu- 
rate and  minute  examination  and  diagnosis.  When  the  gas- 
tric hemorrhage  is  over,  it  will  be  very  easy  to  make  out  the 
gastric  condition;  indeed,  I  have  already  told  you  what  I 
believe  it  to  be. 

As  regards  the  treatment  of  the  hsematemesis,  the  most 
effectual  remedy  is  the  hypodermic  injection  of  Tf[,x  of  the 
fluid  extract  of  ergot  the  minute  that  the  bleeding  begins. 
This  injection  should  be  repeated  if  the  least  symptom  of 
return  of  hemorrhage  appears.  We  shall  keep  up  this 
woman's  strength  by  means  of  such  food  as  eggs,  milk,  beef- 
tea,  etc.,  by  enema.  If  there  is  any  sign  of  heart- failure, 
brandy  is,  of  course,  necessary  by  enema.  Lastly,  I  shall 
order  several  small  blisters  to  be  placed  over  the  epigastrium. 
In  this  way  you  see  that  we  are  treating  and  nourishing  the 
patient  without  putting  a  drop  of  anything  in  her  stomach. 
Should  this  treatment  not  be  successful,  I  should  order  f^x 
of  turpentine  and  gr.  l/24  of  morphia  in  emulsion,  by  the 
mouth,  every  third  hour. — Dr.  DaCosia. 

GRAVES'  DISEASE. 

In  the  treatment  of  this  disease  Dr.  Pepper  gives  the 
greatest  care  to  the  removal  of  the  causes,  and  towards  secur- 
ing rest,  good  food,  change  of  scene  and  entire  release  from 
care.  The  various  functions  are  attended  to,  and  any  local 
disorder  in  females  is  removed  by  suitable  treatment.  Digit- 
alis has  been  found  to  be  the  most  valuable  remedy  for  con- 
trolling the  functional  disturbance  of  the  heart.  It  is  given 
freely,  in  doses  of  from  ten  to  fifteen  drops,  three  or  four 
times  a  day,  and  continued  for  long  periods.  When  anaemia 
exists,  large  doses  of  iron  are  administered.  Most  excellent 
results  have  been  obtained  from  the  injection  of  diluted  solu- 


28  Notes  of  Hospital  Practice. 

dons  of  ergotina  into  the  enlarged  thyroid  gland.  The 
needle  is  introduced  to  the  depth  of  half  an  inch  or  an  inch, 
and  from  six  to  ten  minims  of  a  solution  containing  96  grains 
of  ergotina  to  the  f  1  j  of  distilled  water  was  injected.  Bromide 
of  potassium  has  been  found  to  assist  the  iron  and  ergot  in  regu- 
lating the  action  of  the  heart. 

INFLAMMATIONS    OF    THE   NASAL   PASSAGES,     EUSTACHIAN 
TUBES   AND    MIDDLE   EAR. 

A  solution  of  zinc  is  applied  through  the  catheter.  To  do 
this,  the  catheter  is  first  introduced,  and  then  three  or  four 
minims  of  a  solution  (3/5  gr.  to  the  f  lj)  of  zinc  are  dropped 
into  it.  The  zinc  is  forced  through  the  catheter  into  the  ear 
by  means  of  Politzer's  bag.  In  some  cases  nitrate  of  sil- 
ver is  applied  to  the  diseased  surface  by  means  of  a  post-nasal 
syringe  introduced  behind  the  soft  palate.  In  old  cases  of 
catarrh  of  the  middle-ear,  where  the  secretions  have  ceased, 
the  attempt  is  often  made  to  stimulate  the  membrane.  This 
is  done  by  means  of  ether.  From  8  to  10  gtt.  of  ether 
are  dropped  into  Politzer's  bag.  The  patient  takes  some 
water  in  his  mouth,  and  holds  it  there.  A  nose-piece  is  put 
in  his  nose,  and  just  as  he  is  swallowing  the  water,  the  ether 
is  squeezed  through  the  nose-piece  into  the  passages. 

With  regard  to  constitutional  measures :  where  the  disease 
has  been  hereditary,  and  has  run  through  many  generations, 
the  case  will  only  go  on  from  bad  to  worse,  unless  something 
be  done  to  bring  up  the  general  tone.  If  there  be  any  stru- 
mous  diathesis,  the  bichloride  of  mercury  is  given  internally 
for  a  long  time,  and  in  small  doses. 

Dr.  George  Strawbriclge  regards  the  following  as  a  good 
form  of  administration  of  the  drug : 

R     Hydrarg.  chlo.  corrosivi gr.  3^. 

Elix.  cinchonas f^68*       ^ 

SIG. — To  be  taken  two  or  three  times  a  day,  after  meals. 


General  Diseases,  29 

Iron  and  strychnia  are  given  in  pill  form.  In  old 
people,  where  there  is  very  decided  lessening  of  the  secretions, 
ten-grain  doses  of  the  muriate  of  ammonia  are  given  thrice  daily. 
Before  administering  this  dose  it  is  dissolved  in  f3j 
of  the  elixir  of  cinchona,  and  this  again  suspended  in  half  a 
pint  of  acid  water.  Muriate  of  ammpnia,  like  iodide  of  potas- 
sium, is  never  administered  to  the  stomach  unless  in  a  highly 
diluted  state. 


THE  NIGHT-SWEATS   OF   PHTHISIS. 

"  I  have  treated  the  night-sweats  very  successfully  in  this  and 
other  cases  with  granules  of  atropia — 1/gQ  to  1/60  of  a  grain 
every  night  before  retiring.  This  atropia  treatment  was  first 
started  at  the  Pennsylvania  Hospital,  and  it  has  been  very 
generally  adopted  elsewhere,  as  the  best  means  of  checking 
colliquative  sweats,  both  in  phthisis  and  in  other  affections; 
after  taking  from  I/go  to  1/gQ  of  a  grain  of  atropia  every  night 
for  four  or  five  nights,  the  sweating  is  usually  entirely  checked. 
It  has  been  objected  to  this  atropia  treatment  that  it  produces 
great  dryness  of  the  throat.  I  have  endeavored  to  counteract 
this  effect  by  the  use  of  strong  lemon-juice,  lemonade,  gum- 
water,  or  slippery  elm  conjointly  with  the  atropia.  Quite  re- 
cently I  have  obtained  the  very  best  results  by  means  of 
jaborandi  combined  with  the  atropia.  The  doses  of  jaborandi 
must  be  exceedingly  small.  I  have  not  yet  made  trial  of  this 
combination  in  a  sufficient  number  of  cases  to  enable  me  to 
make  an  authoritative  statement.  All  I  can  say  is  that  I 
have  been  able  to  produce  entire  toleration  of  the  atropia  in 
every  case  in  which  the  jaborandi  was  combined  with  it.  The 
atropia  checks  the  great  drain  of  the  sweats  upon  the  system, 
and  so  gives  the  other  remedies  a  chance  to  act." — Dr.  J.  M. 
DaCosta. 


30  Notes  of  Hospital  Practice. 

CONTAGION   IN  SCARLET   FEVER. 

On  April  30th,  1878,  a  very  severe  case  of  scarlet  fevei 
appeared  in  the  boys'  ward  of  the  Children's  Hospital.  The 
boy  attacked  occupied  a  bed  near  the  centre  of  the  room. 
Coincident  with  this  was  a  similar  case  in  the  girls'  ward.  Both 
of  these  wards  are  on  the  second  floor.  The  cases  were  at  once 
removed  to  the  upper  story,  where  wards  are  prepared  for  such 
contagious  diseases  as  arise  among  the  house  patients. 

Within  a  week  previous  to  his  removal  this  boy  had  been 
successively  changed  from  two  beds  to  a  third,  and  immedi- 
ately afterwards  these  two  beds  had  been  occupied  by 
other  boys.  No  other  case  occurred  in  either  of  these  wards. 
In  a  ward  on  the  third  story,  front,  were  a  number  of  chil- 
dren suffering  from  whooping-cough,  a  disease  which  had  run 
riot  throughout  the  house,  but  was  then  upon  the  decline. 
The  ward  adjoining  this  was  the  one  devoted  to  the  scarlet 
fever  patients.  Among  the  whooping-cough  cases,  on  the  2d 
of  May,  a  girl  manifested  the  characteristic  symptoms  of  scar- 
let fever,  and  was  transferred  to  the  adjacent  ward.  Not 
another  one  of  these  cases  of  pertussis  took  the  scarlet  fever, 
notwithstanding  the  fact  that  the  girl  already  attacked,  who 
was  well  grown,  and  was  suffering  also  from  keratitis  in  addition 
to  the  cough.  She  acted  as  nurses'  assistant,  and  in  this  capacity 
repeatedly  came  in  contact  with  the  other  children  in  the 
ward. 

Ten  days  after  the  last  date,  on  May  12th,  two  very  mild 
cases,  occupying  beds  very  remote  from  each  other,  broke  out 
in  the  back  ward  on  the  second  floor.  These  last  were  so 
faintly  marked  that  they  might  have  been  overlooked  but  for 
the  suspicions  excited  by  the  prevalence  of  the  disease.  On 
the  1st  of  June  one  other  case  occurred  in  this  ward.  On 
May  4th  another  case  occurred,  a  boy  suffering  from  a  slight 
deformity,  and  confined  to  the  "play-room,"  so-called — a 
room  below  the  first  floor,  opening  directly  upon  the  play- 
ground. The  children  from  this  part  of  the  house  seldom 


Genera/  Diseases.  31 

came  in  contact  with  those  in  the  upper  wards,  and  theii  only 
in  exceptional  cases.  Twenty-four  days  after  the  isolation  of 
this  last  boy,  one  other  case,  that  of  a  girl,  occurred  in  the 
"  play-room." 

From  these  facts  it  would  seem  that  contagion  is  not 
the  most  important  element  in  the  spread  of  this  disorder. 
We  must  rather  look  to  individual  susceptibility  coupled  with 
similarity  of  circumstances.  Nor  has  mere  physical  weakness 
much  to  do  with  this  susceptibility.  Lying  very  near  most 
of  the  cases  above  mentioned  were  children  suffering  from  a 
great  variety  of  troubles,  both  medical  and  surgical.  Only 
one  or  two  in  an  entire  ward  were  attacked.  During  the  time 
which  elapsed  from  the  incipiency  of  the  first  to  the  conval- 
escence of  the  last  case,  between  eighty  and  ninety  general  pa- 
tients were  treated  in  the  house.  Only  nine  of  these  took  the 
scarlet  fever.  Of  all  the  patients  in  the  house,  but  half  had 
had  the  scarlet  fever.  The  first  boy  attacked  had  been  in  the 
house  seven  weeks  before  the  manifestation  of  the  angina, 
which,  in  his  case,  was  unusually  severe.  He  could  scarcely 
have  come  in  contact  with  any  one  carrying  the  "  seeds  of  the 
fever"  after  entering  the  house.  This  case  was  by  far  the 
most  severe  of  all,  resulting  in  death.  None  of  the  others 
died.  Each  case  was  milder  than  the  preceding  one — an  evi- 
dence that  the  most  susceptible  are  those  first  attacked.  To 
but  one  case  was  there  the  sequela  of  albuminuria.  This 
child  was  also  suffering  from  a  severe  bronchitis,  and  at  the 
outset  of  the  fever  was  much  emaciated.  The  presence  of  the 
albumen  was  first  detected  on  the  nineteenth  day.  There  was 
little  else  to  suggest  danger,  except  a  trace  of  blood  in  the 
urine,  Prompt  treatment  held  this  symptom  in  check,  how- 
ever, and  by  three  weeks'  time  the  blood  and  albumen  had 
both  disappeared  from  the  urine.  The  bronchitis  meanwhile 
was  all  gone,  and  the  child  improved  in  color  and  flesh. 
Keratitis  in  two  cases  was  much  improved  by  the  fever. — Dr 
James  H.  Hutchinson. 


32  Notes  of  Hospital  Practice. 

PATULOUS  AORTIC  VALVE  ACCOMPANYING  CHRONIC 
BRIGHT'S  DISEASE. 

The  patient  was  found  lying  unconscious  in  the  street. 
When  brought  into  the  hospital  his  pupils  were  contracted 
and  his  breathing  stertorous.  The  radial  arteries  were  very 
tortuous.  One-sixth  of  the  bulk  of  the  urine  was  found  to 
consist  of  albumen.  The  fseces  were  passed  involuntarily. 

Immediately  upon  admission  the  man  was  given  gtt.  ij  of 
crotou  oil  in  a  teaspoonful  of  olive  oil,  and  a  dose  of  the  fol- 
lowing prescription  : 

R     Spts.  chloroform!  (B.  P.) gtt.  xxx. 

Acid,  benzoici gr.  vj. 

Potas.  bicarb gr.  xxx.     M. 

SIG. — Drops  ten  every  two  hours,  in  water. 

For  sustenance  the  patient  took  three  pints  of  milk  and  one 
pint  of  beef-tea,  together  with  f  f  j.  of  alcohol,  the  milk  and 
beef- tea  being  given  in  small  quantities  at  short  intervals. 

Atropia  was  injected  into  the  eyeball,  but  did  not  dilate  the 
pupil  sufficiently  to  enable  the  visiting  physician  to  examine 
the  eye-ground  with  the  ophthalmoscope. 

When  examined  carefully  by  Dr.  John  Forsyth  Meigs,  on 
the  day  after  admission,  the  right  side  of  the  patient's  mouth 
was  found  to  be  paralyzed.  So,  too,  were  the  right  arm  and 
right  leg — the  leg  less  so  than  the  arm.  T'ie  man  was  still 
dull  and  inattentive.  His  respirations  were  44  to  the  minute, 
and  his  pulse  116.  The  radial  arteries  wound  along  like 
worms,  and  pulsated  visibly  from  the  elbows  to  the  wrists. 
Another  curious  fact  in  connection  with  the  case  was  the 
presence  of  rounded,  hard  tumors  on  the  back  of  his  elbows 
and  over  his  phalangeo-metacarpal  joints.  One  of  these 
tumors  was  opened,  and  a  very  thick,  creamy  matter  escaped, 
which  yielded  crystals  of  tyrosin  under  the  microscope.  It 
was  impossible  at  that  time  to  detect  any  murmur  of  aortic 
regurgitation. 

In  endeavoring  to  reach  a  correct  diagnosis  in  the  case,  the 


General  IKseases.  33 

visiting  physician  was  led  at  first  to  regard  the  case  as  one  01 
opium-poisoning,  owing  to  the  marked  2ontraction  of  the 
pupils ;  -but  this  view  of  the  case  was  invalidated  by  the  facts 
of  paralysis  and  stertorous  breathing.  It  was  finally  deter- 
mined that  the  case  was  one  of  chronic  Bright's  disease,  and 
the  opinion  unhesitatingly  advanced  that  further  examination 
would  reveal  the  presence  of  tube-casts,  and  that  when  the 
more  violent  symptoms  had  subsided  a  regurgitant  cardiac 
murmur  would  be  heard.  Mention  was  made  of  the  state- 
ment advanced  by  Walsh,  of  London,  viz.,  that  the  tortuous- 
ness  of  the  arteries  present  in  the  case  is  only  present  in 
patulous  aortic  orifice  and  coarctation  of  the  aorta. 

Subsequent  events  proved  this  diagnosis  to  be  the  correct 
one. 

The  patient's  comatose  condition,  dependent  upon  the 
ursemic  poisoning,  was  found  to  yield  very  markedly  to  the 
following  prescription,  recommended  by  Dr.  George  Johnson, 
of  London,  viz. : 

£     Scammonii  resinse ~ gr.  v. 

Potassii  bitart gr.  xx. 

Zingiberis .. gr.  viij.     M 

Sio. — To  be  administered  when  needed. 


RHEUMATOID   ARTHRITIS  AND  CHRONIC  ECZEMA. 

James  Talbot,  white,  set.  41,  iron  worker.  Admitted 
July  30th,  1874.  Twenty  years  before  that  time  he  went 
to  the  Isthmus  of  Panama  in  charge  of  a  storehouse,  and 
remained  there  four  months,  during  which  time  he  contracted 
Panama  fever,  consisting  of  chills,  fever  and  night  sweat,  fol- 
lowed by  general  debility.  He  returned  to  Philadelphia  very 
much  reduced  in  health  and  has  never  since  recovered  from 
the  effects  of  this  disease.  Fifteen  years  ago  he  was  attacked 
for  the  first  time  with  inflammatory  rheumatism,  beginning 
suddenly  in  the  feet  and  extending  thence  to  the  various  other 
joints  of  the  body.  He  was  confined  to  bed  for  nine  months, 


34  Notes  of  Hospital  Practice. 

the  feet,  ankles  and  hands  enlarging  and  becoming  painful. 
He  remained  in  a  partially  crippled  condition  for  five  years 
being  better  and  worse  from  time  to  time.  Seven  years  ago, 
while  at  work  excavating  a  well,  he  was  again  attacked  with 
rheumatism,  accompanied  by  great  pain  in  the  joints  and  by 
general  stiffness.  Upon  this  occasion  he  kept  his  bed  for 
fifteen  months  and  experienced  a  most  severe  attack.  He 
never  recovered  entirely  from  this  illness,  and  found  himself 
becoming  more  and  more  involved  from  mouth  to  month. 
Three  years  ago  the  disease  had  increased  to  such  an  extent 
that  he  was  forced  to  stay  in  his  bed  permanently.  His  feet, 
hands,  and  all  the  larger  joints  were  greatly  swollen  and  dis- 
figured. He  now  began  to  get  steadily  worse,  both  as  regards 
deformity  and  suffering.  The  rheumatic  symptoms  all  became 
more  marked  and  showed  no  disposition  to  leave  him.  He 
became  entirely  unable  to  use  any  of  his  joints  and  even  to 
turn  in  bed.  He  has  been  on  his  back  for  the  last  two  years. 
During  this  time  he  has  gradually  lost  flesh,  notwithstanding 
that  his  appetite  has  been  good.  His  bowels  have  been  con- 
stipated. He  has  never  had  any  skin  disease  of  any  kind 
until  one  'year  ago  when  his  present  trouble  began  to  show 
itself  on  his  right  foot,  around  the  back  of  the  foot  and  on 
the  instep.  The  left  foot  soon  became  similarly  affected. 
Later  the  hands  and  arms  were  attacked,  and  by  degrees,  in 
the  course  of  six  months,  the  trunk  became  involved.  Patient 
states  that  the  eruption  started  about  the  large  toe  nail,  which 
loosened  and  came  away,  and  was  followed  by  a  crust  formation. 
These  crusts  came  off  from  time  to  time  leaving  a  reddish, 
discharging  surface,  and  finally  all  the  toe  nails  became  de- 
tached. At  this  time  there  was  no  itching,  but  about  eight 
months  ago  itching  began  and  was  most  severe  about  the  legs 
and  arms. 

Present  condition. — The  skin  of  the  face,  scalp,  shoulders, 
arms,  abdomen,  penis,  legs  and  feet,  is  involved  in  a  low 
grade  of  eczema.  The  disease  is  diffiused  in  patches  of  vari- 
ous sizes,  and  is  most  marked  upon  the  lower  extremities.  The 


General  Diseases.  35 

• 

skin  is  boggy  and  red,  giving  forth  a  copious  secretion  of  liquid 
with  a  certain  amount  of  blood,  which  dries,  forming  exten- 
sive crusts.  On  some  parts  of  the  feet  there  is  maceration 
of  the  epidermis,  showing  the  rete  mucosum  in  an  exposed 
state.  The  nails  of  the  toes  are  all  in  a  soft,  broken-down 
condition  and  loosely  attached  to  the  matrix.  Upon  the 
calves  of  the  legs  are  small,  abraded  patches  of  papular  eczema. 
The  knees  also  are  similarly  affected.  About  either  side  of 
the  throat  at  the  anterior  termination  of  the  ribs  are  two 
patches  of  inflamed  skin,  resulting  from  the  constant  pressure 
of  the  hands  upon  these  parts.  The  hands  and  fingers  are 
covered  with  large,  yellowish  crusts,  which  can  readily  be  de- 
tached, exposing  beneath  a  soft  pulpy  substance,  from  which 
serum  and  blood  constantly  ooze.  The  skin  upon  the  other 
portions  of  the  body  is  more  or  less  shriveled,  dry  and  scaly. 
A  very  low  state  of  vitality  of  the  cutaneous  surfaces  is  every- 
where to  be  seen.  Patient  lies  upon  his  back  and  is  unable 
to  move  from  this  position.  The  thighs  are  flexed  upon  the 
body  and  the  legs  upon  the  thighs.  The  joint  trouble  and 
the  contraction  of  the  tendons  fixes  the  limbs  in  this  position. 
The  feet  are  everted  to  almost  a  right  angle  with  the  legs,  and 
are  immovable.  The  arms  are  fixed  across  the  abdomen.  The 
left  hand  abducted  and  fingers  immovably  flexed.  The  right 
hand  is  less  markedly  distorted,  and  the  fingers  are  extended. 
The  lower  jaw  is  almost  fixed  and  he  is  unable  to  masticate 
anything  solid.  Appetite  good  and  is  in  good  spirits.  Urine 
has  a  specific  gravity  of  1015,  and  contains  red  albumen  or 
sugar.  He  sleeps  pretty  well,  but  is  kept  awake  during  the 
early  part  of  the  night  by  pain  in  the  joints  and  limbs.  Res- 
piration 16,  pulse  84.  Bowels  constipated,  was  ordered  pulv. 
aloes,  gr.  j  ;  ext.  colch.  comp.,  gr.  j  ;  ext.,  hyoscy.,  gr.  ss.,  at 
night,  and  his  body  to  be  washed  with  castile  soap  and  water, 
and  then  sponged  with  liq.  picis  alk.  f  3  to  Oj,  iind  also  an 
ointment  of  acid,  carbol.,  gtt.  x,  ung.  zinc,  benzoat.,  f  ij,  to  be 
applied  after  the  tar  wash. 

Aug.  8th,  1874. — Has  been  steadily  improving  as  regirds 


36  i    Notes  of  Hospital  Practice. 

the  eruption,  healthy  skin  in  extending  all  directions,  particu- 
larly upon  the  feet,  where  its  advances  can  be  daily  noted. 
Had  a  despondent  nervous  attack  yesterday.  Bowels  not 
moved  for  three  days,  so  repeated  laxative  pills.  One  or 
more  of  the  joints  are  moved  daily  by  the  nurse.  Patient  is 
taken  out  upon  his  bed  into  the  open  air  for  an  hour  or  more 
a  day,  according  to  his  condition,  weather  permitting. 

Aug.  28th. — Prostrated  somewhat  by  a  nervous  attack. 
Pain  in  limbs,  more  motion  than  formerly,  skin  improving, 
steam  bath  administered  in  bed  and  continued  twenty  min- 
utes. Pulse  increased  from  88  to  115. 

Sept.  Sth. — Steam  bath  to  lower  limbs. 

Sept.  22d. — Slept  comfortably ;  better  than  he  has  been  for  two 
years.  General  condition  improving.  Omit  tar  alkaline 
wash.  Decidedly  more  motion  in  joints  than  formerly. 

Oct.  1st. — Eruption  changing  from  squamous  to  papular 
and  vesicular,  particularly  upon  the  lower  limbs. 

Oct.  7th. — Some  little  improvement,  appetite  good.  Con- 
tinue the  same  treatment  and  diet,  milk  punch  daily,  and  ale 
in  evening.  External  application  of  green  soap  and  alcohol. 
Complains  of  soreness  and  stiffness  in  jaws  on  account  of 
taking  ct)ld,  some  increase  in  number  of  blebs  on  legs. 

Oct.  14th. — Motion  of  joints  improving.  Blebs  not  quite 
so  numerous. 

Oct.  29tli. — Decidedly  better.  Legs  and  feet  much  im- 
proved, ordered  ol.  morrhuse,  f  3ss.,  t.  d.,  and  stopped  potas. 
iod.  mixture. 

Nov.  9th. — Ordered  a  pill  of  ferri  proto.  carb. ;  gr.  ij,  pulv. 
glycr.,  gr.  ij ;  sacc.  alb.,  gr.  iv.,  t.  d.  Also  an  ointment  of 
amyl,  §  iij,  zinci  ox.,  iiij;  hydrarg.  chlor.  mit.,  3  iv,  to  be 
applied  to  limbs  and  body  night  and  morning. 

Nov.  18th. — Blebs  very  numerous  and  confined  to  the  calves 
of  the  legs.  This  increased  quantity  of  blebs  seems  to  con- 
tradict the  idea  that  they  are  caused  by  the  potas.  iod.,  for  that 
medicine  was  discontinued  long  since.  Ordered  the  iron  pow* 
ders  to  be  stopped. 


General  Diseases.  37 

Dec.  \st. — No  improvement.  Ordered  tr.  ferri  chlor.,  gtt. 
V,  in  liq.  pot.  arsenitis,  n\j,  thrice  daily. 

Feb.  2d,  1875. — Patient  has  been  no  better  for  last  two 
months.  Feet  almost  in  same  condition.  No  material  change 
except  a  little  lessening  in  number  of  bullse. 

Feb.  2'2d. — Pain  in  joints  is  very  severe  now.  No  change 
in  condition  of  skin. 

Mar.  15th. — Use  tar  ointment  on  feet  and  legs.  Stopped 
the  ointment  of  calomel. 

April  25th. — No  change.  Ordered  a  prescription  of  hydrarg. 
chlor.  corros.  and  alcohol. 

Aug.  24th. — Discharged  to-day  unimproved.  For  the  past 
two  months  he  has  been  taking  little  or  no  medicine,  and  there 
has  been  no  change  in  his  condition.  About  August  1st,  1878, 
he  died  in  another  hospital  in  this  city. — Dr.  Louis  A.  Duhring. 

DILATATION    OF  THE  STOMACH. 

The  endeavor  is  made  by  Dr.  Cohen  to  produce  contraction 
of  the  walls  of  the  stomach  by  washing  out  the  ingesta  with 
the  stomach-pump,  and  then  rinsing  out  the  stomach  with  a 
solution  of  some  disinfectant.  The  double  effect  is  thus  had 
of  cleansing  and  gymnastic  exercise.  In  inserting  the  stom- 
ach-pump the  head  of  the  patient  is  turned  back,  and  the 
tube  is  passed  down  the  oesophagus  over  two  fingers  placed  in 
the  mouth  as  a  guide.  This  treatment  by  the  stomach-pump 
is  persevered  in  for  a  long  time.  The  stomach  is  well  rinsed 
)ut  at  each  sitting.  To  get  rid  of  remnants  of  food,  emetics 
are  employed.  The  patient's  general  tone  is  sustained  by 
tonics. 

«.       ACNE   ROSACEA. 

Dr.  F.  F.  Maury  treated  this  condition  by  the  local  applica- 
tion of  a  mercury  plaster.  The  alimentary  tract  is  kept  thor- 
oughly open  by  a  methodical  course  of  salines,  such  as  Epsom 


38  Notes  of  Hospital  Practice. 

and  Glauber  salts,  and  Crab  Orchard  and  Hunyadi  Janos 
water. 

In  addition  to  the  mercury  plaster  as  a  local  application, 
the  following  lotion  was  ordered  for  the  face : 

R  Sulphuris  sublim sjij. 

Etheris 3uj- 

Vini  frumenti q.  s. 

Ft.  lotio. 

The  patient  was  advised  not  to  drink  anything  but  a  little 
red  or  white  wine,  and  to  be  careful  to  refrain  from  fish  and 
too  much  meat. 

TINEA  FAVOSA. 

The  hair  is  first  pulled  out  by  the  roots,  the  parasites  killed, 
and  the  scabs  poulticed.  Before  beginning  to  pull  out  the 
hair,  however,  the  whole  head  is  closely  shaved.  The  separ- 
ate hairs  are  pulled  out  with  delicate  tweezers.  These  hairs 
are  pulled  out  in  their  long  axis,  otherwise  they  would  be 
liable  to  break  off  short.  The  poultice  is  applied  immedi- 
ately after  the  hairs  are  pullcxl  out,  so  that  the  pustules  may 
be  well  softened.  After  applying  the  poultice  some  parasiti- 
cide— such  as  the  iodide  of  sulphur,  or  the  bichloride  of  mer- 
cury— is  rubbed  in.  The  parasiticide  most  frequently  used  by 
Dr.  J.  Solis  Cohen  is  that  formed  by  adding  gr.  ij  of  sulphur 
iodide  to  §  i  of  lard. 

SCIATICA. 

i  . 

In  Dr.  Bennett's  hands  hypodermic  injections  of  one- 
eightieth  of  a  grain  of  atropia  and  one-eighth  of  a  grain  of 
morphia  directly  into  the  substance  of  the  affected  muscle 
have  always  afforded  immediate  relief,  although  this  relief,  as 
a  usual  thing,  is  only  temporary.  In  cases  of  sciatica  Dr. 
Starr  has  injected  the  one-eightieth  of  a  grain  of  atropia  intc 
the  tissues  directly  over  the  track  of  the  painful  nerve  with 
manifest  benefit.  Dr.  Wharton  Sinkler,  in  several  cases  of 


General  Diseases.  39 

local  rheumatism,  has  tried  the  local  injection  of  ether — gtt. 
x  in  water.  Though  this  injection  generally  relieves  the 
pain,  yet  it  is  of  itself  always  a  most  painful  operation,  owing, 
no  doubt,  to  the  local  irritation  caused  by  the  ether. 

"When  there  is  distinct  local  inflammation  I  am  accus- 
tomed to  treat  the  disease  with  large  doses  of  iodide  of  potas- 
sium and  minute  doses  of  the  bichloride  of  mercury.  As 
there  is  not  much  pressure  exerted  upon  the  nerve-trunks  in 
this  case,  the  iodide  of  potassium  will  suffice.  If  we  desire 
to  cause  absorption  of  inflammatory  matters  inside  the  sheath, 
the  best  way  to  do  so  is  by  means  of  severe  blistering  or  by 
the  use  of  the  actual  cautery.  The  actual  cautery,  in  particu- 
lar, has  great  absorbent  action,  and  powerfully  relieves  over- 
sensibility  of  the  nerves.  In  this  present  instance  I  have 
been  using  the  actual  cautery  with  the  greatest  success  at  the 
points  where  the  pain  has  been  most  marked.  Another  excel- 
lent treatment  is  by  hypodermic  injections  of  morphia  and 
atropia  right  down  into  the  adjacent  muscular  structures. 
For  this  purpose  we  are  in  the  habit  of  using  here  from  one- 
sixth  to  one-fourth  of  a  grain  of  morphia  and  from  one-nine- 
tieth to  one-sixtieth  of  a  grain  of  atropia.  In  employing  this 
formula  you  must  be  careful  as  the  disease  subsides  that  the 
opium  habit  is  broken.  Indeed,  the  formation  of  such  a 
habit  should  be  guarded  against  by  intermitting  the  treatment 
from  time  to  time.  In  still  other  cases,  again,  Avhere  the 
localized  pain  has  been  intense,  I  have  derived  most  excellent 
results  from  the  hypodermic  injection  of  from  eight  to  twelve 
minims  of  chloroform,  taking  great  care  to  keep  the  needle 
out  of  the  way  of  the  arteries.  Though  incomparable  as  a 
temporary  destroyer  of  pain,  the  effects  of  the  chloroform  are 
not  very  permanent.  Before  leaving  the  subject  I  may  refer 
to  the  use  of  electricity  in  these  cases.  Galvanism  is  very 
quick,  in  some  instances,  to  relieve  pain.  The  mode  of  appli- 
cation should  be  with  the  positive  pole  at  the  seat  of  the  pain 
and  the  negative  pole  along  the  nerve-trunk.  Where  the 
muscles  have  wasted  to  any  great  extent  the  faradic  current  is 


40  Notes  of  Hospital  Practice. 

the  best.  By  some  of  the  above-mentioned  agents  you  wil. 
generally  be  able  to  cut  short  the  course  of  the  disease." — Dr. 
Wm.  Pepper. 


HAEMOPTYSIS. 


Dr.  Starr  has  injected  hypodermically  from  two  to  three 
drops  of  the  fluid  extract  of  ergot  in  this  condition  with  most 
excellent  effects,  always  rapidly  stopping  the  hemorrhage. 


SACCHARINE    DIABETES. 

The  diet  upon  which  a  diabetic  patient  is  placed  consists, 
for  breakfast,  of  eggs,  and  any  kind  of  meat,  except  oysters,  glu- 
ten bread,  and  tea  or  coffee,  with  milk  and  without  sugar ;  for 
dinner,  tomatoes,  lettuce,  onions,  spinage,  string  beans,  meat, 
light  sour  wine,  and  lemons,  or,  perhaps,  oranges,  but  none  of 
the  sweet  fruits;  for  supper,  about  the  same  as  for  breakfast. 
None  of  the  starchy  foods,  no  alcohol,  and  no  sugar  are 
allowed. 

Among  drugs,  opium  is  considered  the  most  valuable  by 
Dr.  Pepper.  Of  this  an  immense  amount  can  be  taken  daily, 
it  has  been  found,  without  producing  any  of  the  symptoms  of 
poisoning.  One  patient  with  this  disease  took  seven  grains 
of  opium  per  day.  In  this  case  the  only  bad  effect  was  the 
production  of  obstinate  constipation.  In  some  cases,  even 
this  was  unnoticed.  The  opium,  by  directly  diminishing  all 
the  secretions,  or  more  probably  by  its  action  on  the  nerve 
centres,  relieves  the  excessive  thirst  and  voracious  appetite, 
and  reduces  the  amount  of  urine  and  of  sugar  in  the  urine. 
In  one  case  the  daily  amount  of  urine  was  reduced  by  the  use  of 
this  drug,  from  twenty-eight  to  eleven  pints.  Ergot,  which  has 
been  found  to  ad:  in  simple  diuresis  almost  like  a  specific,  is 
used  in  saccharine  diabetes  with  much  profit,  in  doses  of  one 
drachm  of  the  fluid  extract  four  times  a  day.  Where  the 
skin  is  dry  and  rough,  jaboraudi  has  been  found  to  be  of 


General  Diseases.  41 

value,  by  reason  of  its  great  powers  of  diuresis.     The  opium 
and  ergot  are  stopped  while  the  jaborandi  is  being  used. 

GASTRIC   VERTIGO. 

The  best  treatment  has  been  found  by  Dr.  DaCosta  to  con- 
sist in  regulating  the  diet  and  in  the  administration  of  bitter 
tonics  and  of  alkaline  waters,  such  as  Vichy  and  Karlsbad. 
These  waters  are  taken,  of  course,  after  meals.  The  general 
tone  of  the  stomach  is,  at  the  same  time,  invigorated  by  the 
use  of  bitter  tonics  before  meals.  Later  on  in  the  course  of 
the  disease,  iron  is  used  in  combination  with  strychnia.  In 
some  cases  corrosive  sublimate  has  been  found  to  exert  a  most 
beneficial  influence  upon  the  gastric  and  cerebral  phenomena. 

The  hypodermic  injection  of  dialyzed  iron  has  been  tried, 
but  the  results  have  not  been  invariably  good,  owing  to  the 
unreliability  of  the  solution.  The  ammonio-citrate  of  iron 
has  proved  more  reliable,  and  five  grains  of  it  in  fifteen  min- 
ims of  distilled  water,  have  been  injected  under  the  skin  of 
patients  with  excellent  results. 

ADDISON'S  DISEASE. 

Rest  is  regarded  by  Dr.  Pepper  as  the  chief  indication,  and 
with  it  good  hygienic  influences  and  wholesome  food.  In 
some  cases  an  exclusive  milk  diet  has  been  found  to  do  great 
good.  The  bowels  and  kidneys  are  carefully  regulated.  No 
long  journeys  are  allowed.  The  system  is  sustained  upon 
arsenic,  iron,  and  cod-liver  oil.  Counter-irritation  over  the 
seat  of  the  disease  is  useful  in  early  stages,  as  is  also  faridiza- 
tiou  with  mild  currents.  Nitrate  of  silver  and  iodide  of 
potassium  are  administered  upon  general  principles.  The 
former  drug  has  been  found  to  be  of  great  use  where  there  is 
irritability  of  the  stomach  and  intestines.  Where  the  vomiting 
is  violent  and  otherwise  uncontrollable,  chlorodyne  is  used. 
Where  there  is  palpitation  and  dyspnoea,  digitalis  lias  been 


42  Notes  of  Hospital  Practice. 

found  to  be  invaluable.  The  forms  of  iron  usually  employed 
are  the  iodide  and  sesquichloride.  A  prescription  frequently 
used  is  the  following,  recommended  by  Greenhow : 

R     Ferri  susquichlo. 

Chloroform! aa    tt\,  xv-xi. 

Glycerins f^j.  M. 

Sio. — Three  times  a  day,  in  water. 

Not  much  confidence  is  placed  in  phosphorus.  Alcohol  is 
given  in  small  quantities  and  in  whatever  form  it  is  best  as- 
similated by  the  stomach.  Strychnia  has  done  good  in  some 
cases. 

CHRONIC    PSORIASIS. 

Dr.  DaCosta  uses  an  ointment  of  chrysophanic  acid  with 
the  strength  of  one  drachm  of  the  acid  to  an  ounce  of  simple 
cerate.  This  ointment  is  well  rubbed  into  the  skin  of  the 
whole  body  every  evening.  After  this  treatment  has  been 
persevered  in  for  four  days,  the  skin  becomes  much  paler 
and  smoother,  and  the  scales  begin  to  disappear. 

PERITYPHLITIS. 

In  the  treatment  of  this  condition,  the  main  indications  art' 
rest,  alteratives  and  counter-irritation,  in  the  shape  of  blisters 
over  the  site  of  pain,  and  induration.  In  some  cases  ice  bags- 
are  of  service  as  local  applications.  The  bowels  are  kept 
open  by  mild  laxatives.  Indian  hemp  and  bromide  of  potas- 
sium are  often  of  service.  The  following  drugs  have  been 
found  to  form  an  excellent  laxative  pill  to  be  taken  at  bed- 
time : 

R     Aloes gr.  j. 

Ex.  cannabis  ind gr.J-. 

Pulv.  ferri  sulph gr.  j.    M. 

Et  in  pil.  No.  j.  Divide. 

If  there  is  much  hardening  of  the  surrounding  tissues  a 
protracted  course  of  the  chloride  of  mercury  and  iodide  of 


General  Diseases.  43 

potassium  in  minute  doses  is  prescribed  by  Dr.  Pepper.     In 
this  condition  pregnancy  must  be  avoided. 

CONSTRICTION    OF    THE    AORTA    WITH    HYPERTROPHY    OP 
THE   HEART. 

J.  S.,  set.  nineteen,  single,  was  admitted  into  the  hospital  on 
February  10th,  1879,  and  placed  in  Dr.  James  Hutchinson's 
ward.  The  patient's  history  shows  that  his  mother  had  died 
of  inflammation  of  the  lungs,  that  his  father  is  still  alive,  but 
suffers  from  heart  disease,  and  that  his  brother  and  sister  are 
in  good  health.  In  early  life  he  appears  to  have  been  free 
from  disease  of  all  kinds,  and  positively  states  that  he  has 
never  had  rheumatism  or  venereal  disease.  His  habits  have 
always  been  temperate.  About  a  year  ago  he  had  intermittent 
fever,  while  living  near  the  Delaware,  at  Port  Richmond, 
which  was  quotidian  in  type,  and  lasted,  at  intervals,  through- 
out the  winter.  During  the  following  spring  and  summer  he 
seems  to  have  been  in  his  ordinary  health,  but  in  the  fall 
caught  a  severe  cold,  which  was  accompanied  by  pain  in  the 
chest  and  small  of  the  back,  cough,  bloody  expectoration,  and 
frequent  micturition,  which  kept  him  in  bed  for  two  months. 
While  convalescing  from  the  acute  symptoms  of  this  attack, 
he  suffered  from  dyspnoea,  and  noticed  that  his  abdomen  was 
beginning  to  enlarge.  There  has  been  no  oedema  of  the  lower 
extremities  or  of  the  face. 

When  admitted  he  was  still  suffering  from  cough,  which 
was  unaccompanied  by  expectoration  of  blood.  The  patient 
is  anasmic,  but  not  emaciated,  and  is  rattier  small  and  unde- 
veloped for  his  age.  His  appetite  is  good ;  his  tongue  moist 
and  but  slightly  coated ;  his  bowels  are  constipated  and  his 
Lands  somewhat  cyanotic.  He  suffers  from  constant  dyspnoea. 
His  urine  is  passed  in  small  quantity  ;  it  is  of  a  clear  amber 
color,  and  contains  a  slight  amount  of  albumen  (1/12  of  bulk,) 
but  no  tube  casts.  Its  specific  gravity  is  1025,  and  its  reac- 
tion acid. 


44  Notes  of  Hospital  Practice. 

The  impulse  of  the  heart  is  felt  in  the  sixth  interspnee 
external  to  the  line  of  the  nipple,  and  is  heaving.  Percus- 
sion shows  that  the  organ  is  enlarged  in  every  direction.  At 
the  apex  a  loud,  blowing  murmur  is  heard.  At  the  base  a 
systolic  murmur  is  also  heardrboth  to  the  right  and  left  of  the 
sternum,  but  less  distinctly  than  at  the  point  of  impulse.  These 
symptoms  and  signs  must  have  been  present  for  at  least 
twelve  months,  as  lie  states  that  he  applied  and  was  rejected 
by  the  medical  examiner  of  the  school  ship  about  a  year  ago, 
on  account  of  heart  disease.  There  is  a  small  amount  of  liquid 
'in  the  peritoneal  cavity,  and  the  superficial  veins  upon  the 
right  side  of  the  abdomen  are  very  much  enlarged,  indicating 
probably  some  interference  with  the  portal  circulation. 

Feb.  15£A.— The  effusion  in  the  abdomen  is  increasing.  The 
liver  can  now  be  plainly  felt,  extending  three  fingers'  breadth 
below  the  arch  of  the  ribs  in  the  mammary  line  and  also  in 
the  mid-sternal  line.  Its  surface  is  smooth  and  free  from 
nodules.  The  amount  of  urine  passed  in  twenty-four  hours 
is  less  than  a  pint.  The  patient  has  been  taking  since  his 
admission  Basham's  mixture  and  broom  tea,  which  have  not 
yet,  however,  produced  any  increase  in  the  flow  of  urine. 

March  Wth. — The  patient  has  been  steadily  getting  worse 
since  date  of  last  note.  He  constantly  expectorates  blood,  and 
his  dyspnoea  is  distressing  to  witness.  All  attempts  to  in- 
crease the  urinary  secretion  have  failed,  although  several  dif- 
ferent diuretics  have  been  given.  On  the  other  hand,  the 
abdominal  effusion  has  been  steadily  increasing,  until  now  his 
abdomen  measures  38J  inches  in  circumference.  With  a  view 
of  diminishing  the  effusion  he  was  ordered  to  have  gr.  £  of 
elaterium. 

March  16th. — Notwithstanding  the  free  purgation  which 
was  induced  by  elaterium,  the  effusion  has  increased  to  such 
an  extent,  and  the  dyspnoea  is  so  distressing,  that  it  was  thought 
necessary  to  resort  to  tapping,  when  10J  pints  of  liquid  were 
removed.  The  patient  bore  the  operation  perfectly  well.  A 
day  or  two  ago  a  teaspoonful  of  the  fluid  extract  of  jaborandi 


General  Diseases.  46 

was  given,  but  the  depression  which  followed  the  sweating 
induced  by  it  was  so  extreme  that  it  was  thought  not  wise  to 
repeat  the  dose. 

March  17th. — Patient  died  this  morning  at  7  o'clock.  He 
reacted  fairly  after  the  operation  and  passed  a  comfortable 
day,  but  in  the  night  was  restless,  and  died  in  the  morning 
apparently  from  syncope. 

March  18th. — Atdopsy  twenty -seven  and  a  half  hours  after 
death ;  chest  and  abdomen  only  opened.  The  lungs  were 
found  congested,  especially  the  base  of  right  lung.  Through- 
out the  left  lung  were  numerous  infarctions ;  the  heart  was 
very  much  enlarged,  weighing  when  emptied  of  the  fluid 
blood  and  clots  which  it  contained,  24  oz.  Its  walls  were 
in  a  relaxed  condition,  but  were  very  much  hypertrophied. 
All  the  cavities  were  dilated,  especially  the  left  ventricle. 
The  mitral  orifice  readily  permitted  the  passage  of  the  four 
fingers  of  the  hand,  thus  showing  a  marked  insufficiency  of 
the  valve.  The  aortic  semilunar  valves  were  healthy,  but 
just  above  the  point  of  origin  of  the  coronary  artery,  which 
was  enormously  enlarged,  the  aorta  was  constricted,  the  strict- 
ure only  allowing  the  point  of  the  little  finger  to  pass  through 
it.  Beyond  the  stricture  the  aorta  was  small,  being  little 
more  than  half  the  usual  diameter;  the  ductus  arteriosus  was 
closed.  The  liver  weighed  three  pounds.  Its  projection  be- 
yond the  arch  of  the  ribs  was  not  so  marked  as  during  life. 
External  to  the  mammary  line  it  was  covered  by  them,  but 
within  the  two  mammary  lines  it  extended  fully  two  inches 
btlow  them.  Its  substance  was  firm  and  congested.  The 
gall  bladder  contained  about  half  an  ounce  of  thick,  viscid  bile. 
In  the  fissures  of  the  liver  were  found  some  enlarged  glands, 
two  of  which  were  situated  so  as  to  compress  the  portal  vein 
at  its  point  of  entrance  into  the  organ.  There  was  thicken- 
ing and  oedema  of  the  cellular  tissue  in  the  neighborhood,  but 
no  traces  of  previous  inflammation.  The  spleen  was  not  en- 
larged, but  was  deeply  congested ;  the  kidneys  were  also  con- 
gested, but  were  otherwise  apparently  healthy. 


46  Notes  of  Hospital  Practice. 

THERMIC  FEVER. 

Dr.  H.  C.  Wood  advises  that  the  patient  should  be  imme- 
diately placed  in  an  ice-water  bath,  and  should  be  kept  in  the 
water  just  long  enough  to  reduce  the  temperature,  as  taken  in 
the  mouth  or  rectum,  to  100°,  and  no  longer.  After  removal 
from  the  bath  a  hypodermic  injection  of  qninia  is  given,  to 
prevent  another  rise  of  temperature. 

The  headache,  slight  elevation  of  temperature,  general  dis- 
tress and  mental  hebetude,  which  sometimes  accompany  con- 
valescence from  thermic  fever,  are  generally  found  to  yield  to 
free  blistering  of  the  back  of  the  head  and  neck,  aided  by 
small  and  repeated  doses  of  mercury. 

ACUTE  TONSILLITIS. 

Dr.  Pepper's  abortive  treatment  is  by  counter-irritation  by 
iodine  over  the  sub-maxillary  region,  and  astringent  washes  to 
the  tonsils,  such  as  dilute  Monsel's  solution,  or  strong  nitrate 
of  silver  (gr.  Ix.  to  f  I  j,)  solution.  Guaiacum,  in  the  shape  of 
a  three-grain  lonzenge,  is  given  every  three  hours.  In  folli- 
cular  tonsillitis,  guaiacum  has  been  found  to  effect  a  cure  in 
the  course  of  forty-eight  hours  in  every  case.  The  following 
prescription  has  been  found  to  be  of  great  service : 

R     Quinise  sulph gr.  ij. 

Tine,  ferri  chlor Tt^  xv. 

Potassii  chlor gr.  v.     M 

SIQ. — To  be  given  every  three  hours,  dissolved  in  syrup  and  water. 

Tho,  patient  is  in  all  cases  put  to  rest  in  bed  and  maintained 
oil  liquid  diet.  If  the  enlargement  of  the  gland  is  very  great 
it  is  lanced  at  once,  provided  pus  has  formed.  As  soon  as  the 
suppuration  ceases,  astringent  poultices  are  applied  to  th« 
neck. 


General  Diseases.  47 

COLLAPSE. 

The  hot  bath  is  employed  to  restore  caloric,  and  moderate 
doses  of  whiskey  and  ammonia  are  given  internally.  At  the 
same  time,  from  ten  to  fifteen  minims  of  the  tincture  of  digi- 
talis are  administered  hypodermically,  in  order  to  restore  car- 
diac action. 

Rubbings  with  warm  cloths  dipped  in  the  tincture  of  cap- 
sicum, followed  by  the  application  of  dry  heat  and  wrappings 
in  blankets,  in  some  cases  replace  the  hot  bath,  but  have  not 
been  found  to  be  as  efficient. — Dr.  Wood. 

ACUTE  ANGINA. 

Salicylic  acid  has  acted  most  admirably  in  a  case  of  very 
severe  acute  angina,  attended  with  a  great  rise  in  temperature, 
Ten-grain  doses  of  the  acid,  given  at  intervals  of  two  or  three 
hours,  reduced  the  patient's  temperature  from  105°  to  99°  in  • 
the  space  of  two  days.  This  fall  of  temperature  was  perma- 
nent.— Dr.  Pepper. 

ACUTE   AND   CHRONIC   RHEUMATISM. 

Dr.  Pepper  continues  to  use  salicylic  acid  as  an  antiphlo- 
gistic, in  these  cases,  with  very  marked  success.  The  dose 
in  cases  of  acute  rheumatism  is  ten  grains  every  two  or 
three  hours,  given  either  in  powder,  or  diffused  in  mucilage 
of  acacia.  A  very  decided  reduction  of  temperature  is  usually 
shown  in  several  hours.  In  chronic  rheumatism  ten-grain 
doses  are  given  thrice  daily,  with  the  like  beneficial  effects. 

Dr.  DaCosta  prefers  the  sal  icy  late  of  sodium  to  tlie  pure 
salicylic  acid. 

Dr.  Stille  recommends  in  chronic  rheumatism  a  prescription 
much  used  in  England,  the  so-called  "  Chelsea  Pensioner," 
from  the  fact  of  its  being  first  used  among  the  rheumatic  old 
pensioners  at  the  Chelsea  Home. 


48  Notes  of  Hospital  Practice. 

Its  ingredients  are  as  follows : 

R     Sulphur '.....„ 3ij. 

Cream  of  tartar g  j. 

Powd.  rhubarb 3  ij. 

Guaiacum  (resin) jjj. 

Clarified  honey ftj. 

Powdered  nutmeg sjij.    M. 

Sio. — Take  two  large  teaspoonfuls  at  night  and  morning,  for  three 
days,  in  honey  or  mulled  wine. 

Dr.  Pepper  has  great  confidence  in  Zollikoffer's  mixture : 

R     Pulv.  resin,  guiaci, 

Potas.  iodidi aa    gr.  x. 

Tinct.  colchici  seni  f^ss. 

Aq.  cinnam. 

Syrnpi aa  q.  s.  ad  jf  j.       M. 

Sio. — A  dessertspoonful  to  a  tablespoonful,  thrice  daily. 

ACUTE   AND   CHRONIC  DYSENTERY. 

The  patient  is  brought  to  the  edge  of  a  hard  bed  and  placed 
in  a  position  somewhat  resembling  that  of  lithotomy,  his 
buttocks  resting  upon  a  hard  pillow  in  such  a  way  as  to 
elevate  the  pelvis,  and  cause  the  injected  fluid  naturally  to 
flow  downwards  and  inwards.  The  "Simon  gravity  injec- 
tion," is  then  employed  in  the  following  manner :  a  well- 
oiled,  smooth,  somewhat  flexible,  hard  tube,  with  openings  in 
the  sides  (an  cesophageal  tube  is  what  Dr.  H.  C.  Wood  usually 
makes  use  of),  and  with  a  closed  end,  is  gently  and  slowly 
introduced  from  eight  to  twelve  inches  into  the  rectum.  The 
free,  outer  end  of  this  tube  is  connected  with  a  Davidson's 
syringe,  and  the  fluid  to  be  injected  thus  slowly  pumped  in. 
Sometimes  the  end  of  the  oesophageal  tube  is  united  to  a  flex- 
ible India-rubber  tube,  in  the  end  of  which  a  funnel  is  placed. 
This  funnel  being  then  elevated  some  five  or  six  feet  above 
the  patient's  rectum,  the  medicated  water  is  poured  into  it,  and 
so  by  its  own  weight  forces  its  way  into  the  gut.  Instead  of 
using  a  funnel,  the  tube  may  be  so  arranged  as  to  empty  a 
bucket  or  other  reservoir,  which  has  been  placed  at  the  proper 
height. 


General  Diseases.  49 

The  liquid  injected  is  in  all  instances  first  heated  to  th<> 
temperature  of  the  body,  and  so  does  not  provoke  peristaltic 
movement.  The  solution  of  nitrate  of  silver  used  by  Dr. 
Wood,  has  a  strength  of  3  j  to  the  three  pints  of  water.  The 
injection  usually  comes  away  in  from  five  to  ten  minutes.  A 
solution  of  common  salt  is  always  at  hand,  and  should  be  at 
once  thrown  into  the  bowel  if  the  nitrate  of  silver  solution 
does  not  come  away  in  the  course  of  ten  minutes.  The  same 
treatment  has  been  also  pursued  with  success  in  chronic 
dysentery. 

Dr.  Pepper  uses  a  solution  containing  only  ten  grains  to  the 
quart,  and  introduces  at  first  a  pint  and  then  a  quart  of  the 
solution  twice  daily,  at  first,  and  afterwards  once  in  two  days. 

GOITRE. 

Dr.  Roland  Curtin's  successful  mode  of  treatment  has  con- 
sisted in  the  hypodermic  injection  of  from  six  to  ten  minims 
of  a  solution  containing  ninety-six  grains  of  ergotina  to  the 
ounce  of  distilled  water.  The  injection  is  repeated  two  or 
three  times  a  week  for  the  space  of  from  four  to  six  months, 
when  the  gland  becomes  thoroughly  hardened.  The  gland 
begins  to  shrivel  with  the  stoppage  of  the  injections,  and  very 
soon  returns  to  its  normal  size.  Ergotina  has  been  proved  to 
be  of  no  value  in  bronchocele,  but  only  in  cases  of  simple 
enlargement  of  the  thyroid  gland.  The  injection  is  attended 
with  but  very  little  pain,  which  pain  is  generally  local,  or 
referable  to  the  origin  of  the  steruo-cleido-mastoid  muscle. 

DYSPEPSIA. 

Among  drugs,  arsenic  in  small  doses,  gradually  increased, 
has  been  found  to  be  a  remedy  of  extreme  importance. 
Where  there  is  torpor  of  digestion  joined  with  very  marked 
sympathetic  nervous  disturbances,  Dr.  Pepper  uses  the  follow- 
ing formulae* 


50  Notes  of  Hospital  Practice. 

1.  R     Sodse  bicarb  ........................  .  ........................  ijiij. 

A«id  hydrocyan,  dil  .........................................  gtt.  xlviij. 

Tinct.  valerian!  ..............................................  f^  j. 

Syrup  zingiberis  .............................................  f3j  ij.  M 

SiG.  —  A  teaspoonful  thrice  daily,  in  water. 

2.  R     Quinise  sulph  ................  .  .................................  gr.  xvi. 

Strychniae  sulph  ...............................................  gr.  J. 

Acid,  rauriat.  dil  ............................................  f.^jss- 

Syrup,  zingiberis  ...................................  q.  s.  ad  f  ^  iv.  H. 

SIG.  —  Two  teaspoonfuls  in  water,  right  after  meals. 

Where  there  is  marked  hepatic  disturbance,  the  following 
prescriptions  are  excellent  : 

S      R     Acid,  muriat.  dil  ...............  ...................................  f^ss. 

Tine.  nuc.  vom  ......................................................  f^ss. 

Infu.  gentianse  corap  ...................................  q.  s.  ad  f  J  iv.   M. 

SIG.  —  A  teaspoonful  in  water  after  meals. 


4.      R     Bismuth,  subnit 

J'epsime...  ............................................................  o  j-ss- 

Strychnise  sulph  ...................................................  gr.  j. 

Tinct.  cardamon.  comp  .................................  q.  s.  ad  fjiv.    M. 

SIG.  —  A  teaspoonful  thrice  daily,  in  water.  If  there  is  much  flatulence, 
an  increase  is  made  in  the  quantity  of  bi&muth  and  pepsin.  If  the  case  be 
merely  one  of  gastric  atony,  the  amount  of  strychnia  is  increased. 

Where  there  is  marked  gastralgia,  two  to  five  drops  of 
Fowler's  solution  are  administered  during  the  paroxysms. 
If  this  does  not  control  the  pain,  a  blister  two  inches  square 
is  applied  to  the  epigastrium,  and  followed  by  a  belladonna 
plaster  six  inches  square. 

Where  the  stomach  is  weak,  its  muscular  action  impaired, 
and  its  nerves  over-sensitive,  but  little  food  should  be  taken 
into  it  at  a  time.  The  best  diet  is  skimmed  milk,  half  a  pint 
every  four  hours.  When  milk  is  not  well  digested,  lime-water 
is  combined  with  it.  Such  foods  as  coffee,  tea,  and  tobacco 
must,  of  course,  be  given  up  absolutely  and  at  once.  A 
sovereign  article  of  diet  is  buttermilk.  In  buttermilk  the 
casein  of  milk  is  coagulated  and  broken  up,  so  that  the  stom- 
ach is  spared  two  steps  of  the  .regular  process  of  digestion. 


General  Diseases.  51 

Another  excellent  preparation  of  milk  is  kourayss.  It  eon- 
tains  a  good  deal  of  carbonic  acid.  In  all  cases  the  stomach's 
work  is  made  easier  by  a  diet  consisting  of  eggs,  milk, 
starchy  vegetables,  stewed  fruits,  and  a  little  butter,  with  stale 
bread. 

DIABETES   INSIPIDUS. 

Dr.  DaCosta  puts  the  patient  upon  an  initial  dose  of  half  a 
drachm  of  the  fluid  extract  of  ergot,  thrice  daily.  This  dose 
is  gradually  increased,  first  to  1  and  then  to  2  drachms. 
There  is  almost  immediately  a  great  reduction  in  the  quantity 
of  urine  passed  daily — from  ten  to  three  pints. 

ULCER   OP   THE  STOMACH, 

Nitrate  of  silver,  in  the  form  of  pills,  is  given  in  full  doses 
half  an  hour  before  meals.  If  there  is  pain,  opium,  hydro- 
cyanic acid,  and  chloroform  are  administered.  An  exclusive 
milk  diet  is  the  best.  All  solid  foods  are  avoided.  At  the 
time  of  the  hemorrhage,  Dr.  Pepper  insists  upon  absolute  rest. 
Pieces  of  cracked  ice  are  swallowed  by  the  patient.  Monsel'a 
solution,  tannic,  or  gallic  acid,  are  given  internally.  Morphia 
and  ergotina  are  administered  hypodermically,  and  all  food 
for  the  time  being  (during  the  continuance  of  the  hemorrhage) 
given  by  enemata. 

POST-NASAL   CATARRH. 

Dr.  J.  Solis  Cohen  considers  cleansing  to  be  the  principal 
factor  in  the  treatment.  The  fluid  which  he  employs  for  tliis 
purpose  is  tepid  water  at  about  blood  heat,  brought  up  to  the 
specific  gravity  of  blood,  by  means  of  some  saline — such  as 
the  chloride  or  carbonate  of  sodium.  The  cleansing  operation 
is  persevered  in  until  all  the  accumulations  are  removed.  To 
cleanse  the  passages,  the  patient  dips  his  nose  into  the  vessel 
containing  the  saline  liquid,  and  sniffs  it  up  into  the  pharynx, 


52  Nates  of  Hospital  Practice. 

discharging  it  by  the  mouth;  or  the  rubber-ball  syringe,  with 
a  long  curved  nozzle, 'is  used.  Sometimes  Thudicum's  nasal 
douche  is  employed. 

Another  method  of  local  treatment  is  by  short  flexible 
bougies,  composed  of  gelatine  impregnated  with,  for  example, 
2  grains  of  sulphate  of  zinc,  and  £  grain  of  carbolic  acid.  A 
string  runs  through  the  bougie  and  extends  some  distance  be- 
yond it.  This  is  for  the  purpose  of  securing  the  bougie  so 
that  it  shall  not  drop  into  the  throat.  The  bougie  being  in- 
serted, the  projecting  portion  of  the  string  is  fastened  round 
the  ear.  The  bougie  generally  melts  in  from  twenty  to  thirty 
minutes. 

LUMBAGO. 

Dr.  Pepper  applies  manipulation  to  the  lumbar  region  of 
the  spine,  so  as  to  restore  mobility.  To  subdue  the  painful 
condition  of  the  muscle,  injections  of  !/80  of  a  grain  of  atropia 
and  ^  of  a  grain  of  morphia,  well  diluted,  are  made  well  into 
the  body  of  the  muscle.  Great  care  is  had  in  the  administra- 
tion of  morphia  and  atropia  to  nursing  women,  as  belladonna 
is  the  most  powerful  anti-galactagogue  known,  and  as  toa 
large  doses  of  morphia  not  infrequently  affect  the  child 
through  its  milk.  The  local  application  of  blisters,  iodine, 
and  croton  oil,  together  with  the  internal  administration  of 
iodide  of  potassium,  are  often  serviceable. 

LARYNGEAL   PHTHISIS. 

After  enjoining  absolute  silence,  Dr.  Cohen  applies  the  fol- 
lowing solution  to  the  affected  parts  by  inhalation,  or  by  the 
brush,  douche,  or  spray,  viz. : 

R     Acid.  carb.  concent f£j 

Tinct.  iod.  comp ,"ij. 

Aquae q.s.  ad  f^  iij    M. 

Sio. — One  teaspoonful,  applied  three  or  four  times  daily  in  an  ounce  of 
•rater,  by  douche  or  spray,  or  thrown  in  boiling  water,  and  the  vapor  in- 


General  Diseases.  53 

haled.  The  advantages  of  the  spray  are,  twofold — (1,)  the  water  cleanses, 
and  (2,)  its  impact  upon  the  parts  stimulates.  The  iodine  acts  as  an  ab- 
sorbent, and  the  carbolic  acid  as  a  disinfectant  and  as  an  astringent. 

When  ulceration  begins,  more  powerful  applications  are 
employed.  Here  the  spray  is  still  useful,  for  the  part  is 
cleansed  at  all  times  before  any  local  application  is  made. 
Caution  is  needed,  however,  in  making  use  of  the  spray,  that 
no  irritating  substance  is  employed.  The  inclination  of  an 
ulcerating  surface  is  not  to  heal ;  and  an  irritant,  of  course, 
throws  a  further  obstacle  in  the  way  of  healing.  Where  there 
are  irregular  excrescences  on  the  vocal  cords  or  other  parts  of 
the  larynx,  due  to  exuberant  granulation  following  ulceration, 
they  are,  as  a  general  rule,  allowed  to  remain,  unless  they 
have  grown  to  such  a  size  as  to  interfere  with  respiration.  If 
the  arytenoid  cartilage  becomes  ulcerated,  the  demand  is  for  a 
soothing  application,  such  as  a  weak  solution  of  aconite  and 
glycerine,  or  a  weak  solution  of  morphia  and  belladonna. 
The  chloride  of  zinc,  in  the  form  of  a  weak  solution,  is  an 
excellent  application.  The  action  of  this  remedy  is  limited  to 
the  points  of  ulceration.  That  astringent  substance  is  always 
employed  which  does  the  least  damage  to  the  tissues  surround- 
ing the  ulcers.  The  chloride  of  zinc  is  employed  in  a  solu- 
tion of  one  part  to  fifty,  or  even  one  hundred. 

In  the  later  stages  of  laryngeal  phthisis  the  nitrate  of  silver 
does  good ;  but  it  is  used  without  the  expectation  of  its  curing. 
This  substance  forms  a  coating  of  coagulated  albumen  over 
the  ulcerated  tissue,  and  so  protects  it  from  the  air  and  from 
the  irritation  of  food.  The  solution  of  the  nitrate  of  silver 
used  has  a  strength  of  from  forty  to  sixty  grains  to  the  ounce. 
It  is  applied  merely  to  the  ulcers  at  the  margin  of  the  larynx, 
and  not  to  those  in  its  interior,  which  it  cannot  benefit.  Where 
the  swelling  of  the  parts  interferes  with  respiration,  and  suffo- 
cation is  threatened,  tracheotomy  may  be  necessary  for  the 
prolongation  of  life. 

For  the  oedema  Dr.  Pepper  uses  sulphate  of  zinc,  or  cop- 
per, or  alum.  The  following  is  an  excellent  gargle: 


54  Notes  of  Hospital  Practice. 

R     Tinct.  benzoicicomp , 

Glycerine f.^ss 

Aquae q.  s.  ad  f£  iv.    M. 

SIG. — To  be  used  as  a  gargle. 

Inhalations  of  steam,  of  vapor  of  hops,  or  of  conium,  are 
employed  as  palliatives.  Counter-irritation  is  applied  exter- 
nally to  the  larynx,  in  the  shape  of  small  blisters.  To  relieve 
the  sense  of  fullness,  lozenges  of  krameria,  hsematoxylon,  or 
tannic  acid  are  prescribed. 

THE   OPIUM   HABIT. 

Rest  is  the  first  item  of  the  cure.  The  patient  is  kept  in 
bed.  Ample  nourishment  is  given.  If  there  is  a  morbid 
irritation  of  the  mucus  membrane  of  the  stomach,  the  patient 
is  placed  upon  an  absolute  diet  of  skimmed  milk,  beginning 
with  a  pint  and  running  up  to  two  quarts  daily.  All  this 
time  the  quantity  of  opium  taken  is  progressively  diminished. 
If  the  conjoined  milk  and  opium  produce  constipation,  the 
condition  is  overcome  by  massage.  The  abdominal  muscles 
are  well  kneaded  daily.  Regular  injections  of  cod-liver  oil 
are  given  in  the  morning,,  followed  by  cold  water  injections  at 
night.  Iron  is  administered  in  large  and  gradually-increasing 
doses.  I>ialyzed  iron  is  the  form  of  chalybeate  generally 
employed.  It  is  given  in  doses  of  from  10  drops  to  1  fluid 
drachm  thrice  daily, — £h'.  Wm.  Pepper. 

ANEURISM. 

Dr.  James  Hutchinson  has  seen  considerable  benefit  derived 
from  the  administration  of  very  large  doses  of  the  iodide  of 
potassium.  In  one  case  lately  under  his  charge  as  much  as 
60  grains  of  this  drug  was  taken  thrice  daily  without  produc- 
ing iodism,  and  with  the  effect  of  quite  markedly  diminishing 
the  size  of  the  aneurism. 

Another  patient  under  the  charge  of  Dr.  Levis  was  put 
upon  the  iodide  of  potassium  in  gradually-increasing  doses, 


General  Diseases.  55 

oeginning  with  5  grains  three  times  a  day,  and  gradually 
increasing  the  dose  until  he  finally  took  3  drachms  morning, 
noon  and  night,  without  producing  iodism.  He  was  also 
given  aconite,  as  an  adjuvant  to  the  iodide  of  potassium,  in 
much  the  same  manner ;  beginning  with  1  drop  of  the  tinct- 
ure of  the  root,  and  gradually  increasing  the  amount  to  5 
drops  three  times  a  day.  His  diet,  too,  was  regulated,  and 
his  manner  of  living  changed.  His  diet  was  fair,  as  regards 
quantity,  but  was  made  up  of  substances  which  do  not  tend  to 
fatten.  Its  composition  consisted  mainly  of  albuminous  or 
nitrogenized  articles  of  diet,  with  a  careful  avoidance  of  all 
kinds  of  stimulants.  He  lived  as  quietly  as  possible,  lay  down 
a  great  deal  during  the  day,  and  kept  himself  free  from  any 
excitement.  Rest  is  considered  a  very  important  element  in 
the  treatment  of  this  class  of  cases. 

Under  this  plan  of  treatment  the  man's  condition  improved 
very  much.  He  has  been  slowly  increasing  in  strength  ;  there 
has  been  a  marked  improvement  in  his  general  health,  and 
apparently  the  aneurismal  sac  is  being  gradually  occluded. 
In  other  words,  the  aneurism  is  being  cured  by  a  consolidation 
of  the  sac. 

Some  time  since,  in  the  case  of  an  aneurismal  sac  bulging 
from  the  subclavian  artery,  Dr.  Levis  carried  pieces  of  horse 
hair  through  the  walls  of  the  sac,  and  so  succeeded  in  produc- 
ing partial  coagulation  of  the  blood. 

INFLUENZA. 

Dr.  DaCosta's  treatment  is  pre-eminently  a  supporting 
and  expectant  treatment,  meeting  special  indications  as  they 
arise,  and  treating  symptoms  mainly.  Good  food  (systemati- 
cally given)  and  quinia  are  generally  considered  by  him  as  of 
primary  importance.  Dover's  powders  or  other  diaphoretics 
are  occasionally  used.  A  certain  amount  of  wine  or  milk- 
punch  has  been  found  to  be  indispensable,  particularly  in 
elderly  patients.  The  amount  of  stimulus  is  proportioned 
to  the  severity  of  the  attack. 


56  Notes  of  Hospital  Practice. 

ACUTE   AND   CHRONIC  TUBAL   NEPHRITIS. 

The  dropsy  consequent  upon  this  disease  is  treated  by  Dr. 
DaCosta  with  Basham's  mixture  and  TT^xx  of  the  fluid  ex- 
tract of  jaborandi,  three  times  a  day.  When  the  secretions  of 
the  skin  and  kidneys  are  fully  re-established,  the  jaborandi  is 
discontinued,  and  f3ss  of  the  fluid  extract  of  ergot  is  given 
thrice  daily  in  its  place,  the  Basham  being  continued  with 
the  ergot.  At  the  same  time  the  region  of  the  patient's  kid- 
neys is  rubbed  with  croton  oil.  Exposure  to  cold  and  wet 
it  avoided.  Diet  consists  of  milk  and  eggs  and  nourishing 
broths,  with  very  little  meat.  Digitalis,  belladonna  and  iron 
are  often  of  service. 

UR-EMIA, 

as  a  result  of  disease  of  the  kidneys,  is  treated  with  the  fol- 
lowing prescription : 

R      Acid  benzoici gr.  xz. 

Syrupi  tolutani fgj.        M. 

SIG. — To  be  given  every  third  hour,  largely  diluted  with  water. 

Eenzoic  acid  has  been  found  by  Dr,  DaCosta  to  prevent 
particularly  the  accumulation  of  the  urinary  salts  in  the  blood. 
In  addition  to  this  treatment  the  patient  is  thoroughly  purged 
with  croton  oil.  He  is  also  given  a  warm  bath,  or,  if  he  is 
too  weak,  a  vapor  bath  is  taken  in  bed,  by  means  of  hot  bricks 
wrapped  in  damp  towels.  In  some  cases  dry  cupping  over 
the  loins  does  good. 

CHRONIC   INTERSTITIAL   NEPHRITIS. 

Dr.  DaCof ta  uses  this  formula : 

R     Tinct.  ferri  chloridi n\,x. 

Syrupi  limonis Ti\,l. 

Aquae 
SIQ. — To  be  taken  thrice  daily  in  a  wineglassful  of  water. 

A  little  wine  is  allowed  and  a  nourishing  diet  given. 


SURGICAL  AND  VENEREAL  DISEASES. 

FORIGN  BODY   IN   THE   URETHRA. 

"  On  the  17th  of  July,  1878,  T.  D.,  set.  63,  was  admitted 
into  the  University  Hospital,  for  the  purpose  of  having  a 
fragment  of  a  glass  tube  extracted  from  his  urethra.  D.  gave 
the  following  history  of  his  case :  Has  always  been  strictly 
temperate  in  his  habits,  and  has  never  had  any  affection  of 
his  genito-urinary  apparatus. 

For  several  years  patient  has  been  one  of  a  relief  committee 
of  a  lodge  of  "  Knights  of  Pythias/'  and  while  performing 
the  duties  of  this  position  he  met  several  members  of  this 
order  who  had  great  difficulty  in  passing  urine,  in  consequence 
of  enlargement  of  the  prostate  gland,  and  were  dependent 
on  the  use  of  a  catheter  for  relief.  Fearing  that  he  might 
have  the  same  trouble  at  some  future  time,  and  being  anxious 
to  provide  against  such  a  disagreeable  contingency,  T.  D. 
determined  to  practice  catheterization  on  himself  with  a  glass 
tube.  In  his  first  attempt  he  succeeded  in  passing  a  medium- 
sized  glass  tube  into  his  bladder,  and  drew  off  urine,  without 
the  parts  involved  sustaining  any  injury.  The  success  of  this 
experiment  encouraged  him  to  try  the  operation  a  second 
time,  the  results  of  which  were  less  satisfactory,  as  the  sequel 
will  show.  On  the  day  of  T.  D.'s  admission  into  the  hos- 
pital, he  procured  a  straight  glass  tube,  about  25  centimetres 
(10|  inches)  in  length,  and  half  a  centimetre  in  diameter, 
with  which  he  proposed  to  repeat  self-catheterization.  He 
had  no  difficulty  in  introducing  the  tube  as  far  as  the  pros- 
totic  urethra,  but  at  this  portion  of  the  urethra  the  tube  was 
suddenly  arrested.  D.,  in  his  efforts  to  overcome  the  obstruc- 
tion used  sufficient  force  to  break  the  tube  in  two  nieces,  one 

57 


58  Notes  of  Hospital  Practice. 

of  which  he  immediately  pulled  out  of  the  urethra,  but  the 
other,  being  out  of  his  reach,  was  left  in. 

Shortly  after  D.'s  admission  to  the  hospital,  I  made  an  ex- 
amination, and  found  the  fragment  of  the  glass  tube  fixed  in 
the  urethra,  one  end  in  the  prostatic  portion,  and  the  other 
penetrating  the  wall  of  the  scrotal  part.  The  fractured  end 
of  the  fragment,  D.  had  forced  through  the  floor  of  the  urethra 
into  the  loose  cellular  tissue  of  the  scrotum,  by  his  attempts  to 
get  the  tube  out.  He  had  also  tried  to  expel  the  tube  by 
passing  his  urine ;  but  instead  of  displacing  it,  it  only  served 
to  carry  urine  into  the  scrotum,  through  the  cellular  tissue  of 
which  the  urine  was  quickly  diffused.  From  the  position  in 
which  the  foreign  body  lay  in  the  urethra,  and  the  manner  in 
which  it  was  held  there,  it  was  evident  that  it  could  not  very 
easily  be  extracted  by  any  instrument,  such  as  forceps,  passed 
into  the  urethra.  Nor  could  it  be  removed  through  an  open- 
ing made  in  the  perineum  without  risk  of  doing  additional 
violence  to  the  already  lacerated  urethral  walls.  To  take  it 
out  through  a  perineal  section  would  necessitate  the  breaking 
of  the  fragment  in  two  or  more  pieces  in  the  urethra;  the 
removal  of  which  fragments  would  be  attended  with  consider- 
able danger,  in  consequence  of  the  sharp,  angular  ends  which  the 
pieces  would  have.  In  considering  the  difficulties  of  the  case 
from  all  points,  it  occurred  to  me  that,  in  consequence  of  the 
fractured  end  of  the  broken  tube  being  already  in  the  scrotum, 
the  safest  and  most  practicable  plan  of  removing  the  tube 
would  be,  either  to  make  an  opening  in  the  integuments  of 
the  scrotum,  and  extract  the  tube  through  it,  or  to  introduce 
my  finger  into  the  patient's  rectum,  get  behind  the  smooth 
ejnd  of  the  tube  in  the  prostatic  urethra,  if  possible,  and  push 
the  sharp  end  forward  through  the  scrotal  walls.  As  soon  as 
the  patient  had  been  brought  under  the  influence  of  ether,  I 
directed  two  assistants  to  support  his  legs  in  the  position  that 
they  would  be  held  in  operation  of  lithotomy,  in  order  that 
the  scrotum  and  perineum  might  be  fully  exposed. 

I  new  proceeded  to  introduce  my  right  forefinger  into  the 


Surgical  and  Venereal  Diseases.  W 

patient's  rectum,  carried  it  up  behiud  the  prostate  gland,  till  I 
could  distinctly  feel  the  smooth  end  of  the  tube  through  the 
urethral  wall ;  then,  having  made  the  scrota!  integument  tense 
near  the  fractured  end,  with  the  thumb  and  finger  of  my  left 
hand,  I  quickly  pushed  the  tube  forward  through  the  scrotal 
wall  with  my  right  forefinger.  The  small  wound  of  the  scro- 
tum, made  by  the  operation,  was  instantly  closed  by  contrac- 
tion of  the  dartos  structure.  As  the  scrotum  had  become  in- 
filtrated with  urine  prior  to  the  extraction  of  the  tube,  I  made 
four  free  incisions  in  it,  two  either  side  of  the  raphe,  to  relieve 
tension  and  to  get  rid  of  the  urine,  thereby  to  prevent  subse- 
quent sloughing.  For  eight  days  after  the  operation  the 
patient's  urine  was  drawn  off  three  or  four  times  a  day  with  a 
catheter,  the  utmost  care  being  used  to  prevent  the  escape  of 
any  urine  through  the  wound  in  the  urethra.  At  the  expira- 
tion of  this  period  he  was  permitted  to  pass  his  urine  in  the 
natural  way ;  this  he  was  able  to  do  freely  and  without  pain, 
clearly  showing  that  the  wound  of  the  urethra  had  securely 
healed.  Apparently,  as  a  consequence  of  some  injury  inflicted 
on  one  of  the  testicles  by  the  end  of  the  tube,  a  mild  epididy- 
mitis  developed  itself  soon  after  the  accident;  this  attack, 
however,  yielded  promptly  to  treatment,  and  soon  subsided. 
The  incised  wounds  of  the  scrotum  that  were  made  to  facili- 
tate the  escape  of  urine  from  the  cellular  tissue,  healed  in  a 
short  time  under  the  effects  of  local  applications  of  laudanum 
and  water.  The  patient's  bowels  were  kept  at  rest  for  four  or 
five  days,  and  some  slight  pain  relieved  by  suppositories  of 
opium ;  no  subsequent  medication  was  required. 

In  the  progress  of  this  case  it  is  worthy  of  notice  that  the 
patient  did  not  have  either  a  chill,  or  any  symptoms  of« 
urethral  fever.  On  the  30th  of  July,  D.  left  the  hospital 
quite  well,  with  the  exception  of  a  little  enlargement  of  one 
epididyoiis.  The  length  of  the  fragment  that  was  extracted 
was  10J  centimetres  (about  4£  inches.") — Dr.  C.  T.  Hunter. 


60  Notes  of  Hospital  Ptactice. 

FRACTURED   PATELLA. 

Dr.  Thomas  G.  Morton  has  treated  all  the  cases  of  fracture 
of  the  patella  which  have  been  brought  into  the  wards  for 
several  years  past  with  his  improved  modification  of  Mal- 
gaigne's  hooks.  In  every  instance  the  treatment  has  been 
permanently  successful.  Dr.  Morton's  first  modification  of 
the  Malgaigne  hooks  consisted  in  making  the  hooks  longer 
and  straighter,  but  this  improvement  was  shown  to  be  of  but 
slight  advantage.  Dr.  R.  J.  Levis  then  made  a  further  modi- 
fication of  the  Malgaigne  pattern,  by  cutting  it  into  two  sepa- 
rate pairs  of  hooks.  This  modification  also  was  thrown  aside 
after  using  it  once.  The  last  and  most  useful  modification 
by  Dr.  Morton  consists  in  cutting  the  hooks  into  two  separate 
pairs,  each  pair  consisting  of  one  fixed  and  one  movable  hook. 

At  the  University  Hospital  fractured  patellae  are  treated 
altogether  by  Dr.  AgneVs  splint.  This  consists  of  a  flat  pos- 
terior splint,  with  an  eminence  for  the  popliteal  space,  and 
with  four  rollers  screwing  in  at  the  sides,  two  above  and  two 
below.  Adhesive  strips  coming  down  on  each  side  from 
above  the  broken  bone  are  fastened  to  the  lower  rollers  and 
screwed  tight,  and  corresponding  strips  from  below  are 
secured  in  like  manner  to  the  two  upper  rollers.  The  frag- 
ments are  thus  securely  brought  together.  The  whole  leg  is 
then  bandaged.  This  mode  of  treatment  has  given  most  ex- 
cellent results. 

Dr.  Charles  Hunter  has  lately  invented  a  more  simple 
apparatus  for  the  treatment  of  these  fractures,  and  has  used  it 
in  one  case  very  successfully.  Extension  is  made  by  adhesive 
strips  on  each  side  of  the  leg,  adherent  from  the  groin  to  just 
above  the  seat  of  fracture.  A  weight  is  attached  to  the  free 
ends  of  these  strips,  at  the  bottom  of  the  bed.  The  whole 
leg  is  then  tightly  bandaged  with  figure-of-eight  turns  round 
the  knee.  This  method  will  at  once  adjust  itself  to  the  ne- 
cessities of  country  practitioners,  by  reason  of  its  great  sim- 
plicity. 


Surgical  and  Venereal  Diseases.  61 

HIP-JOINT   DISEASE. 

When  patients  cannot  walk  they  are  treated  in  the  recumb- 
ent position.  Dr.  Agnew  believes  only  in  that  form  of  treat- 
ment which  fixes  the  diseased  joint.  He  believes  in  allowing 
such  patients  to  walk,  if  they  are  able  to  do  so,  but  he  does 
not  believe  in  that  kind  of  walking  which  causes  either  friction 
or  motion  of  the  affected  joint.  The  immobility  of  the  limb 
is  secured  by  a  splint,  which  may  be  applied  either  on  the 
outer  or  the  posterior  aspect  of  the  leg,  thigh  and  body.  The 
sound  limb  is  raised  by  means  of  a  cork-soled  shoe,  and,  if 
sufficiently  old,  the  patient  is  placed  upon  crutches.  This 
plan  has  the  advantage  of  fixing  the  diseased  joint,  and  pre- 
vents the  patient  from  resting  upon  the  affected  limb.  More- 
over, it  admits  of  exercise  in  the  open  air.  This  treatment 
lias  aborted  this  disease  in  several  cases  in  which  it  was  be- 
gun early. 

ELEPHANTIASIS  ARABUM  TREATED  BY  XERVE  SECTION. 

The  patient  was  a  colored  man,  34  years  of  age,  a  farm 
laborer,  and  was  first  admitted  to  the  Pennsylvania  Hospital, 
on  December  1st,  1873.  He  had  been  a  slave  in  Virginia, 
where  he  was  born  and  always  resided  until  after  the  war, 
when  he  came  to  Philadelphia.  His  father  was  crippled  by 
a  fall,  but  was  otherwise  in  good  health ;  his  mother  was  also 
healthy.  He  and  a  younger  brother  were  the  only  ones  out 
of  fifteen  children  who  suffered  from  enlargement  of  the 
limbs.  He  had  never  been  in  Barbadoes.  Fourteen  years 
before  coming  into  the  hospital  he  noticed  the  first  symptoms 
of  increasing  size  of  the  right  leg.  At  first  he  had  some  pain, 
especially  at  night,  but  of  late  years  he  had  been  able  to  work 
as  well  as  any  one,  and  only  felt  inconvenience  from  the 
weight  of  the  limb,  and  from  a  serous  oozing  that  issued  from 
some  abrasions  and  kept  his  foot  cold  and  wet.  His  general 


<J2  Nolcs  of  Hospital  Practice. 

liealth  was  excellent,  tlie  disease  -being  mainly  confined  to  (lie 
right  inferior  extremity,  which  was  markedly  ichthyotic  from 
the  middle  of  the  thigh  down  to  the  instep.  The  skin  and 
superficial  cellular  tissue  were  veiy  much  hypertrophied,  and 
hung  in  large  folds  over  the  ankle-joint.  Under  some  por- 
tions of  the  thick,  scaly  epidermis  there  were  effusions  of  pus. 
The  left  leg  above  the  ankle  was  slightly  enlarged,  but  the 
surface  seemed  natural.  The  skin  of  the  abdomen  showed 
impairment  of  nutrition  and  alteration  of  structure,  which  the 
patient  said  was  the  result  of  a  scald  received  when  he  was 
young. 

Dr.  Thomas  G.  Morton  tied  the  femoral  artery,at  the  usual 
place,  on  December  12th.  The  temperature  of  the  limb,  taken 
on  the  eighth  day  after  the  operation,  was  98°  between  the 
toes,  and  101J°  on  the  surface  of  the  calf,  (the  thermometer 
being  held  in  position  for  one  hour.)  The  axillary  temper- 
ature was  99°.  The  limb  was  enveloped  in  a  poultice  of  flax- 
seed,  in  order  to  remove  the  old  epidermis.  The  ligature  came 
away  on  the  twenty-first  day,  and  the  small  wound  remaining 
speedily  closed.  The  limb  was  then  enveloped  in  a  rollei 
bandage  firmly  applied.  This  bandage  was  exchanged  on 
January  7th,  1874,  for  one  of  India  rubber,  which  was,  how- 
ever, removed  at  the  end  of  four  hours,  on  account  of  its 
producing  numbness.  The  compression  was,  nevertheless, 
resumed  as  a  regular  part  of  the  treatment,  and  the  limb 
gradually  and  steadily  decreased  in  size.  The  patient  was  dis- 
charged on  March  21st,  very  much  benefitted.  [There  was 
a  marked  improvement  after  the  separation  of  the  ligament, 
but,  as  firm  compression  was  steadily  maintained  with  the 
limb  in  a  horizontal  position,  it  was  difficult  to  know  ho\v 
much  of  the  improvement  was  really  due  to  the  operation.] 
The  patient  was  subsequently  admitted  into  the  Philadelphia 
Hospital  and,  by  the  kindness  of  Dr.  John  H.  Brinton,  Dr. 
Morton  had  another  opportunity  of  examining  him.  The 
limb  was  found  to  be  nearly  as  large  as  it  was  prior  to  the 
ligation;  the  patient,  however,  considered  himself  much  im- 


Surgical  and  Venereal  Diseases.  63 

proved,  and  thought  that  the  operation  had  markedly  arrested 
the  progress  of  the  disease. 

The  man  was  re-admitted  to  the  Pennsylvania  Hospital,  on 
November  9th,  1877.  The  right  leg  was  found  to  be  double 
its  size  when  last  seen,  measuring  twenty-one  inches  in  circum- 
ference. From  the  exceedingly  cumbrous  character  of  the 
limb,  the  man  desired  to  have  an  amputation  performed. 
Having  noticed  the  frequency  with  which  operations  for  nerve 
section  are  followed  by  atrophy  of  the  parts  supplied  by  the 
nerve  which  is  cut,  Dr.  Morton  determined  to  attempt  the 
artificial  production  of  atrophy  of  the  right  lower  extremity 
by  section  of  the  motor  nerve  of  that  limb.  Accordingly, 
on  November  17th,  1877,  the  right  sciatic  nerve  was  laid  bare, 
and  one  and  one-half  inches  of  its  length  exsected  at  the  upper 
third  of  the  thigh.  No  unpleasant  symptoms  occurred  after 
the  operation  incident  to  the  section.  There  has  been  a  steady 
diminution  in  the  size  of  the  limb  ever  since.  On  January 
3d,  1878,  the  limb  was  measured,  and  found  to  be  but  twelve 
and  one-half  inches  in  circumference,  a  reduction  of  some  eight 
and  one-half  inches  from  the  last  measurement. 

An  interesting  feature  of  the  case  has  been  the  desquamation 
of  all  the  thick  skin  which  covered  the  limb  from  the  kueo 
to  the  ankle  and  foot,  especially  about  the  lower  third  of  the 
leg;  patches  of  the  skin,  one-sixteenth  of  an  inch  thick,  have 
peeled  off  from  time  to  time,  leaving  a  perfectly  clear,  soft, 
and  pliable  skin  beneath.  There  has  not  been  the  least  dis- 
position on  the  part  of  the  skin  to  ulcerate,  and  the  lost  sensi- 
bility is  confined  to  the  extreme  anterior  portion  of  the  dor- 
sum,  all  the  sole  of  the  foot,  and  a  strip  of  the  integument 
running  directly  up  the  posterior  part  of  the  leg  to  about  the 
middle  point  between  the  heel  and  the  popliteal  space.  This 
strip  is  about  two  inches  in  width  on  all  portions  of  the  leg, 
except  this  anaesthetic  strip ;  the  patient  is  able  to  distinguish 
l>etween  the  compass  points,  provided  they  are  held  at  not  less 
than  one  inch  apart.  Later  still  the  reduction  to  the  size  of 


64  Notes  of  Hospital  Practice. 

the  limb  lias  become  still  more  marked,  so  that  when  last  seen 
the  limb  was  almost  reduced  to  its  normal  size. 


GLEET. 

"  Where  the  system  is  very  greatly  run  down,  it  is  well  to 
put  the  patient  upon  some  such  preparation  as  the  citrate  of 
iron  and  quinine  in  10-grain  doses,  or  20  drops  of  the  tinct- 
ure of  the  chloride  of  iron,  two  or  three  times  a  day,  with  2 
grains  of  quinine.  If,  on  the  other  hand,  the  patient  is  ple- 
thoric, he  should  be  given  some  saline  and  an  antimonial 
mixture.  In  treating  local  symptoms,  it  is  useless  to  give  the 
patient  a  syringe,  and  let  him  use  it  himself,  for  the  injection 
employed  must  be  applied  directly  to  the  diseased  spots,  if 
any  benefit  is  to  be  derived  from  it,  and  no  one  can  so  apply 
it  but  the  educated  surgeon.  Moreover,  such  a  kind  of  ap- 
plication should  be  made  with  a  special  form  of  instrument, 
so  that  it  may  reach  the  diseased  surface,  and  it  only.  There 
are  a  vast  number  of  syringes,  etc.,  which  have  been  designed 
for  tli is  purpose.  Some  years  ago  I  was  accustomed  to  apply 
stramonium  ointment  and  the  nitrate  of  silver  directly  to  the 
parts  by  means  of  one  or  other  of  these  inventions.  The  ap- 
plication would,  of  course,  cause  some  local  irritation.  The 
patient  would  be  dieted  and  sent  to  bed,  and  some  demulcent 
drink,  such  as  flaxseed  or  slippery-elm  tea,  be  administered. 
In  other  cases,  again,  I  used  the  bulbed  syringe,  in  which, 
after  just  passing  the  site  of  the  stricture,  the  stream  is  pro- 
jected backward.  I  have  very  often  medicated  strictures,  by 
means  of  this  instrument,  with  a  strong  solution  of  nitrate  of 
silver,  or  with  a  mixture  of  cerate  of  opium  and  Goulard's 
extract.  Of  late  months  I  have  undergone  a  change  of  opin- 
ion in  the  matter  of  the  treatment  of  gleet.  I  now  think 
that  there  is  nothing  in  the  world  so  good  as  the  introduction 
of  nickel-plated  conical  bougies  and  the  simple  overstretching 
of  the  inflamed  parts." — Dr.  8.  W.  Gross. 


Surgical  and  Venereal  Diseases.  65 

CURVATURE  OF   THE  SPINE. 

In  the  suspension  of  a  child  for  curvature  of  the  spine, 
instead  of  using  the  head-sling,  Dr.  H.  W.  Wharton  attaches 
a  cord  to  the  centre  of  the  crosses  over  the  top  of  the  head  of 
Barton's  bandage.  This  simplifies  the  apparatus,  and  is  less 
terrifying  to  the  child. 

ULCERS. 

Dr.  Charles  Hunter  uses  the  ozide  of  zinc  as  a  protective  in 
ulcers.  This  compound  is  smeared  around  the  edges  of  au 
ulcer 'before  applying  the  adhesive  strips,  and  so  prevents 
excoriation  of  the  skin. 

FRACTURED   CLAVICLE. 

Dr.  D.  Hayes  Agnew  treats  fractured  clavicle  by  perfect 
rest  on  the  back  iti  bed,  with  the  head  slightly  elevated.  But 
as  the  patient  soon  becomes  restless,  and  as  it  is  impossible  to 
secure  perfect  quiet  after  the  third  day  unless  a  nurse  be 
secured  to  arrest  every  motion  of  the  patient  both  by  day  and 
light,  at  the  end  of  that  time  and  when  the  ends  of  bone  have, 
as  it  were,  lost  their  disposition  to  get  out  of  place,  the  patient 
is  raised  carefully  from  the  prone  into  a  sitting  posture,  and 
put  in  restraint  by  the  introduction  of  an  axillary  pad  four 
inches  wide  and  five  inches  long,  and  tapering  rapidly  to  a 
point,  which  elevates  the  arm  and  supports  the  shoulder, 
while  a  long  strip  of  adhesive  plaster,  three  and  a  half  inches 
wide  (Sayre's  dressing),  is  passed  round  the  body  with  a  loop 
to  support  and  elevate  the  arm. 

SURGICAL   SHOCK 

is  treated  by  Dr.  Agnew  by  the    hypodermic,   injection  of 
carbonate  of  ammonium  mixed  with  brandy. 


66  Notes  of  Hospital  Practice. 

CYSTITIS   IN  THE   MALE. 

If  there  is  acute  pain  and  spasm,  blood  is  taken  from  the 
perinseum  by  means  of  leeches.  The  patient  is  kept  in  bed, 
and  hot  fomentations  are  applied  over  the  pubes.  At  the 
same  time  he  takes  demulcent  drinks  with  a  little  hyoscyamus. 
If  the  pain  be  violent,  morphia  is  given  by  the  mouth  or 
rectum. 

The  following  prescription  is  frequently  employed : 

R     Pulv.  opii gr.  xij. 

Camphorse gr.  xxx. 

Ext.  belladonna gr.  iij. 

Cacao q.  s. 

M.  et  in  suppos.    No.  vi. ;  divide. 
Sio. — One  each  night  before  retiring. 

The  diet  employed  is  bland  and  unstimulating. 

After  the  acute  symptoms  have  abated,  balsam  of  copaiva 
is  given  thrice  daily  in  capsule,  or  rubbed  up  in  an  emulsion. 
To  this,  opium  is  occasionally  added  to  prevent  flatulence  and 
griping.  Turpentine  in  capsule  is  used  with  advantage  in 
some  cases.  Other  remedies  are  sometimes  employed — such 
as  buchu,  decoction  of  trailing  arbutus,  or  uva  ursi  with  hops, 
highly  recommended  by  Sir  Henry  Thompson — uvse  ursi, 
f  3  iss. ;  lupulina?,  3  i;  aquae,  Oij.  This  mixture  is  allowed  to 
simmer  for  two  hours;  then  enough  water  is  poured  in  to 
bring  the  quantity  of  the  mixture  up  to  2  quarts,  and  then  2 
grains  of  morphia  and  2  drachms  of  the  bicarbonate  of  sodium 
are  added.  The  dose  of  this  mixture  is  a  wineglassful. 

In  some  cases  benzoic  acid  has  been  found  very  useful. 
The  initial  dose  is  5  grains,  and  the  quantity  is  then  gradually 
pushed  up  to  30  grains,  and,  in  some  instances,  as  much  as 
1  drachm  is  taken  thrice  daily. 

A  prescription  very  often  employed  by  Dr.  S.  W.  Grose 
and  other  members  of  the  hospital  staff  is  the  following: 


Surgical  and  Venereal  Diseases.  67 

R     Copaiba?  balsami .~  iv. 

Acid,  benzoici 9  iv. 

Gummi  arabaci 

Sacchari,  aa     ^ij. 

Gaultherise  olei gtt.  xx. 

Aquae  camphorae, q.  s.  ad  f^viij.      M. 

SIG. — A  tablespoonful  every  four  hours. 

As  regards  the  treatment  of  the  urine,  the  first  thing  that  is 
done  after  dilating  the  stricture,  if  one  exists,  is  to  wash  out 
the  bladder.  This  is  usually  done  in  the  following  manner : 
A  gum-elastic  bag,  holding  about  4  ounces,  is  procured,  and 
a  basinful  of  water  at  98°  is  made  ready.  Then,  after  draw- 
ing the  urine  with  a  flexible  catheter,  whose  end  is  smooth, 
the  bladder  is  washed  out  by  simply  connecting  the  mouth  of 
the  bag  with  the  catheter,  which  has  been  allowed  to  remain 
in  situ.  The  warm  water  thus  injected  is  retained  as  long  as 
possible,  then  drawn  off,  and  the  operation  repeated. 

If  the  urine  is  foetid,  1  grain  of  the  permanganate  of  potas- 
sium or  a  small  part  of  carbolic  acid  is  added  to  each  part  of 
warm  water.  When  the  water  comes  out  clear,  if  it  is  de- 
sired to  make  an  impression  upon  the  mucous  membrane  of 
the  bladder,  a  solution  of  borax  (15  grains  to  the  fluid  ounce 
of  water)  is  injected,  At  other  times  a  20-grain  solution  of 
the  nitrate  of  silver  is  employed.  If  this  solution  does  not 
cause  too  much  smarting  it  is  allowed  to  remain  10  seconds 
in  the  bladder. 

The  patient  is  kept  at  rest  in  bed  during  this  treatment, 
and  placed  upon  a  very  bland  diet.  (If  there  be  any  pain 
after  the  warm-water  injections  have  come  away,  a  little 
morphia  is  thrown  into  the  bladder  and  allowed  to  remain 
there ;  or,  if  this  does  not  afford  relief,  a  hypodermic  injection 
is  given.) 

In  some  bad  cases  it  is  necessary  to  perform  cystotomy,  or 
colotomy,  in  order  to  bring  about  a  free  discharge  of  fluid 
from  the  bladder. 

Patients  with  cystitis  are  warned  not  to  ride  in  wagons 
over  rough  stones;  if  possible,  to  refrain  altogether  from 


68  Notes  of  Hospital  Practice. 

riding.  They  are  advised  to  avoid  all  stimulating  drinks, 
and  to  always  wear  flannel  next  their  skin.  They  are  no< 
allowed  to  eat  any  greasy  food,  but  are  allowed  plenty  of  fish 
and  oysters.  Their  bowels  are  kept  open  by  cold-water  injec- 
tions, or  saline  cathartics. 


PEOSTATOKRHCEA   WITH   STRICTURE. 

Where  the  stricture  is  fibrous,  it  is  gradually  dilated  by 
means  of  Dr.  S.  W.  Gross'  expanding  bougie.  Where  it  is 
spasmodic  and  due  to  hypersesthesia  of  the  urethra,  it  is  treated 
by  the  persevering  introduction  of  conical  steel  bougies  of 
gradually  increasing  sizes.  If  the  nieatus  is  unusually  small 
it  is  slit  up. 

In  obstinate  cases  of  this  nature  astringent  local  applica- 
tions are  necessary,  such  as  nitrate  of  silver,  which  is  applied 
by  means  of  the  porte  caustique  devised  by  Prof.  S.  D.  Gross. 
The  solid  nitrate  is  the  form  of  silver  used.  After  applying 
the  caustic  the  patient  is  kept  in  bed,  his  diet  reduced,  and 
demulcent  drinks  administered  freely. 

If  there  be  constipation,  the  bowels  are  kept  well  open  by 
means  of  an  occasional  purge,  or  the  patient  takes  as  a  routine 
medicine,  each  morning  before  breakfast,  f  §  vi  of  Hunyadi 
Janos  water,  or  the  following  prescription,  which  was  first 
originated  by  the  late  Dr.  Robley  Dunglison : 

R     Mag.  sulphat §j. 

Potass,  bitart 3J. 

Ferri  sulphat gr.  x. 

Aquae q,  s.  ad  Oij.       M. 

Sio. — A  wineglassful  every  morning  before  breakfast. 

Another  excellent  plan  which  is  often  pursued  is  to  inject 
five  or  six  gobletfuls  of  cold  water  into  the  rectum  each 
morning. 

The  diet  provided  is  nutritious  but  bland.  No  coffee,  tea, 
malt  or  alcoholic  liquors,  and  no  greasy  or  fried  foods,  arc 
allowed. 


Surgical  and  Venereal  Diseases.  G£ 

For  breakfast  he  is  given  grits  or  oatmeal,  meat,  and  bread 
and  butter ;  for  dinner,  plenty  of  good  rare  beefsteak  or  mut- 
ton-chop, with  potatoes,  tomatoes,  etc.  Supper  should  be  a 
light  meal. 

If  there  be  any  anaemia,  something  like  the  following  ia 
given : 

li     Quinitesulph gr.  xl. 

Tinct.  ferri  chloridi. f.^iv- 

Tinct.  nucis  vomicse f^ivss. 

Aquae q.  s.  ad  f  ^  ijss.      M. 

Sio. — A  teaspoonful  four  times  daily  in  water,  through  a  siphon. 

If,  on  the  other  hand,  there  is  a  tendency  to  plethora,  de- 
pressants and  purges  are  employed.  The  patient  takes  a  sitz- 
bath  every  night  and  morning.  He  sleeps  on  a  hard  mat- 
tress, empties  his  bladder  thoroughly  before  going  to  bed,  and 
uses  only  the  lightest  of  coverings. 

To  keep  down  the  venereal  appetite,  30  grains  of  the  bro- 
mide of  potassium  are  given  thrice  daily. 

Where  the  condition  is  obstinate,  local  blistering  is  resorted 
to.  A  camel's-hair  brush  is  dipped  in  cantharides  and  col- 
lodion, and  a  couple  of  lines  are  drawn  with  it,  first  on  one 
side  of  the  raphe  of  the  perineum,  and  then  on  the  other. 

Intercourse  is  had  regularly,  so  that  the  distended  seminal 
vessels  may  be  relieved,  but  it  is  never  had  at  shorter  inter- 
vals than  every  two  or  three  weeks. 

Where  there  is  functional  disease  of  the  heart  with  palpita- 
tion, and  flushing  of  the  face,  there  is  nothing  better  than 
digitalis  in  small  and  long-continued  doses.  It  may  be  given 
in  any  of  its  medicinal  forms. 

N^VUS  MATERNA. 

Two  oiled  pins  are  pushed  right  through  the  base  of  the 
growth  so  that  they  cross  each  other  at  right  angles.  A 
groove  is  then  cut  all  the  way  round  between  the  points  of 
entrance  and  of  exit  of  the  pins  with  a  sharp  knife.  A  stout 


70  Notes  of  Hospital  Practice. 

ligature  is  then  passed  round  the  base  of  the  naevus  and  under- 
neath the  pins,  and  is  drawn  so  tight  as  to  completely  stran- 
gulate the  growth.  Dr.  S.  W.  Gross  does  not  believe  in  tem- 
porizing in  these  cases  by  the  use  of  the  cautery  or  by  the 
injection  of  irritating  substances  into  the  body  of  the  tumor. 


are  treated  surgically  by  incising  the  pile  with  a  bistoury,  and 
then  pressing  out  its  contents,  viz.,  the  contained  clot  of  blood. 
This  slight  operation  relieves  the  pain  and  tension  at  once. 
As  an  after-treatment  the  parts  are  well  bathed  with  cold 
water,  and  some  medicine  given  to  act  on  the  liver  and 
bowels.  Dr.  Samuel  D.  Gross  does  not  at  all  believe  in  the 
immediate  removal  of  these  growths  with  the  knife,  as  recom- 
mended by  Erichsen  and  Bryant. 

TAPPING   IN   DROPSY. 

Dr.  J.  Solis  Cohen  treats  obstinate  cases  of  dropsy  of  the 
legs  by  tapping.  The  minute  trocars  which  he  uses  are  made 
of  gold,  with  openings  at  the  ends  and  on  the  sides.  They 
have  sharp  three-cornered  points.  In  inserting  these  canulae 
they  are  thrust  well  into  the  flesh  from  below  upward  and 
then  fastened  in  position  by  strings  tied  to  their  bulbous  ex- 
tremities. These  strings  are  fixed  by  pieces  of  adhesive  plaster. 
When  the  canulae  are  fixed  in  position,  slips  of  rubber  tubing 
are  fastened  to  their  bulbous  extremities.  Where  the  fluid  does 
not  flow  freely  after  the  canulse  is  inserted,  its  flow  is  started 
by  pulling  the  rubber  tubing  between  the  fingers  pressed 
tightly  together,  and  so  creating  a  vacuum.  Care  is  had  not 
to  insert  the  canulae  too  far  down  in  the  limb,  where  their 
presence  may  produce  a  sore,  owing  to  the  weight  of  flesh 
above  them. 


Surgical  and  Venereal  Diseases.  71 

THE   HYPERDISTENTION   OP  ABSCESSES. 

This  treatment  of  abscesses,  first  used  by  Mr.  Callender,  of 
London,  has  been  tried  with  excellent  effects  at  this  hospital. 
The  cases  were  both  of  them  in  the  service  of  Dr.  H.  Lenox 
Hodge.  In  the  first,  that  of  a  large  femoral  abscess  in  a 
child  suffering  with  coxalgia,  the  abscess  was  first  opened  with 
a  bistoury,  and  a  large  amount  of  pus  discharged  by  gentle 
pressure.  A  5  per  cent,  solution  of  carbolic  acid  in  water 
was  then  injected  through  a  common  syringe,  with  tube 
attached,  so  as  to  completely  fill  up  the  abscess  to  overflowing. 
This  hyperdistention  caused  a  number  of  cheesy,  shreddy,  and 
fibrous  particles  to  be  discharged.  No  constitutional  symp- 
toms followed,  and  no  pus  was  to  be  found  subsequently  upon 
the  carbolized  oil-dressing.  The  injection  was  repeated  thir- 
teen days  later.  At  no  time  after  the  first  injection  were 
more  than  a  few  drops  of  pus  exuded. 

In  the  second  case  the  results,  though  fair,  were  not  so  im- 
mediate and  pronounced  as  in  the  first  case ;  the  temperature 
showing  a  constant  tendency  to  rise  and  the  pus  still  continu- 
ing to  be  discharged. 

RAPID  RECOVERY  FROM  DEPRESSED  FRACTURE  OF  THE 
FRONTAL,  BONE. 

The  following  case  occurred  in  the  service  of  Dr.  H.  Lenox 
Hodge :  T.  C.,  set,  4,  while  playing  on  tow-path  of  a  canal, 
was  caught  under  his  chin  by  the  tow-line,  and  thrown 
violently  down  a  bank  estimated  to  be  about  twelve  feet  high. 
His  head  came  in  contact  with  a  piece  of  cinder.  This  acci- 
dent occurred  at  6  P.  M.  on  June  24th.  The  child  was  in  the 
hospital  by  8  P.  M.  Upon  examination,  a  depressed  fracture 
of  the  frontal  bone  about  three-quarters  of  an  inch  above  the 
superciliary  ridge  upon  the  outer  edge  of  the  frontal  eminence, 
was  found.  The  wound  extended  for  some  seven  lines,  and 
was  accompanied  by  much  laceration  of  the  soft  parts.  The 


72  Notes  of  Hospital  Practice. 

pupils  were  widely  dilated.  The  breathing  was  stertorous, 
and  the  condition  that  of  general  hebetude.  The  boy  was  not 
rendered  insensible  by  the  fall,  but  soon  afterward  lapsed  into 
a  comatose  condition,  only  arousing  himself  to  ask  for  water. 

The  treatment  consisted  in  the  coaptation  of  the  sides  of 
the  wound  with  adhesive  strips,  and  in  placing  over  this  a 
dressing  of  simple  cerate.  An  ice-bag  was  applied  to  the 
head  and  a  simple  fever  mixture  given  internally.  The  tem- 
perature immediately  upon  admission  was  99°  F.  The  next 
morning  the  boy  was  bright  and  cheerful ;  complained  of  no 
pain  and  asked  for  food.  His  pupils  were  contracted.  As  a 
precaution  a  catheter  was  passed,  but  its  use  was  not  again 
required. 

June  2Qth. — Bowels  not  yet  opened.  A  dose  of  castor  oil 
given. 

June  27th. — Bowels  still  inactive,  but  boy  very  bright  and 
enters  readily  into  conversation  on  any  topic. 

June  28th, — Bowels  and  bladder  both  acting  regularly. 
Wound  healing.  Boy  takes  nap  or  two  during  day  and  sleeps 
regularly  at  night.  Patient  left  hospital  soon  afterward, 
entirely  well. 

SERIOUS  BURN  FOLLOWED  BY  CONTRACTION  OP  TISSUE- 
CURED  BY  NITRATE  OF  SILVER  AND  PRESSURE  CARE- 
FULLY APPLIED  BY  MEANS  OF  ROLLERS. 

J.  T.  F.,  set.  10,  admitted  to  the  hospital  on  January  14th, 
1879.  This  boy  was  badly  burned,  both  above  and  bel.ow 
the  elbow,  and  completely  around  the  arm.  Before  coming 
to  the  hospital  he  had  been  treated  for  some  six  months  at  his 
home. 

When  first  seen  by  the  resident  surgeon,  Dr.  J.  M.  Taylor, 
the  burn  was  seen  to  have  penetrated  the  muscles  and  showed 
pouting  granulations  of  from  two  to  three  inches  in  diameter, 
encircling  the  arm.  The  elbow  was  much  contracted. 


Surgical  and  Venereal  Diseases.  73 

When  Dr.  John  Ashhurst,  Jr.,  saw  the  case  he  thought  that 
amputation  would  have  to  be  performed.  A  dressing  of  oxide 
of  zinc  was  immediately  applied,  the  discharge  of  pus  at  that 
time  being  considerable.  On  the  20th  of  January,  six  days 
after  admission,  the  granulations  had  very  largely  diminished 
under  the  use  of  the  nitrate  of  silver,  and  in  some  places 
above  the  elbow  the  skin  had  united,  forming  narrow  patches 
of  healthy  epidermis.  On  January  28th  the  granulations 
were  all  healing  rapidly.  On  February  16th  the  arm  was 
entirely  cured. 

The  resident  surgeon,  Dr.  Taylor,  took  great  interest  in  the 
case,  and  each  day  straightened  the  arm  out  carefully  as  far  as 
it  would  go,  seeking  to  make  it  straighter  at  each  visit.  The 
nitrate  of  silver  was  applied  with  great  thoroughness  and 
care,  and  after  each  application  the  arm  was  bound  up  pretty 
tightly  with  turns  of  the  roller  over  an  oakum  pad. 

8PEAIN8. 

The  routine  treatment  of  sprains  pursued  at  the  Philadel- 
phia Hospital,  is  that  first  introduced  by  the  late  Dr.  Paul 
Goddard.  The  injured  part  is  placed  in  a  bath  at  the  tem- 
perature of  70°  F.  The  temperature  of  the  water  is  then 
gradually  raised  until  the  extreme  point  of  toleration  is 
reached.  This  hot-water  treatment  has  in  every  instance  been 
followed  by  the  most  excellent  effects. 

GONORRHOEA  IN  THE  MALE. 

Dr.  J.  H.  Brinton  employs  carbolic  acid,  in  the  shape  of  a 
solution  containing  gtt.  ij  of  the  acid  to  f  §i  of  lime-water, 
as  a  local  application  in  the  acute  stage  of  the  disease.  At 
the  same  time  cubebs  is  administered  internally  in  doses  of  a 
tablespoouful  in  half  a  tumblerful  of  water  three  or  four 
times  a  day.  This  dose  is  pushed  until  diarrhoaa  or  nausea 
supervenes,  when  the  quantity  is  reduced. 


74  Notes  of  Hospital  Practice. 

STRICTUKE. 

Dr.  S.  "W.  Gross  considers  that  the  only  rational  treatment 
of  stricture  consists  in  the  restoration  of  the  normal  calibre  of 
the  urethra  at  the  affected  portion,  and  that  the  meatus  should 
therefore  be  enlarged  so  as  to  admit  of  the  passage  of  an  in- 
strument of  the  size  adapted  to  restoring  the  constricted  part 
(whose  dimensions  may  be  ascertained  by  means  of  the  ure- 
thrometer  devised  by  Dr.  Gross)  to  its  original  dimensions. 
Dr.  Gross  claims,  however,  that  dilatation  never  effects  a  per- 
manent cure,  and  should  therefore  never  be  employed  except 
in  those  cases  where  there  is  disease  of  other  portions  of  the 
urinary  apparatus. 

He  treats  stricture  almost  entirely  at  present  by  internal 
urethrotomy,  since  he  has  determined  from  post-mortem  ex- 
aminations that  there  are  very  often  sub-mucous  bands  which 
resist  the  action  of  the  divulsor. 

Having  determined  upon  internal  urethrotomy,  he  first 
allays  the  spasm  and  tenderness  of  the  urethra  by  passing  at 
first,  and  at  long  intervals,  a  moderate-sized  conical  steel  bou- 
gie, gradually  increasing  the  size  of  the  instrument  and  de- 
creasing the  length  of  the  intervals.  If  the  meatus  is  the  seat 
of  stricture,  or  is  smaller  than  the  rest  of  the  urethra,  it  is  cut 
as  a  preliminary  measure. 

Ten  grains  of  quinia  are  given  before  the  operation,  and  the 
patient  is  made  to  pass  his  water  so  that  the  wound  left  by 
the  urethrotome  may  have  become  glazed  before  the  next  act 
of  micturition.  The  rectum  is  always  emptied  before  the 
operation.  Dr.  Gross  employs  a  urethrotome  devised  by  him- 
self, and  made  by  Mr.  G.  Tiemann,  of  New  York. 

Immediately  after  the  operation  a  conical  steel  bougie, 
whose  size  corresponds  to  that  of  the  normal  urethra,  is  passed 
and  withdrawn,  and  £  of  a  grain  of  morphia  is  thrown  under 
the  skin.  The  patient  is  then  confined  to  bed  for  forty-eight 
hours.  The  bougie  should  be  introduced  once  every  day  foi 
some  time  after  the  operation.  Dr.  Gross  considers  internal 
urethrotomy  from  behind  forward  the  most  effectual  oneration. 


Surgical  and   Venereal  Diseases.  75 

The  treatment  of  stricture  of  the  urethra  followed  by  Dr. 
Briii ton  is  not  an  exclusive  one  In  the  majority  of  cases  he 
relies  upon  gradual  dilatation,  especially  when  (he  stricture  is 
situated  at  or  near  the  membranous  portion  of  the  urethra. 
In  making  dilatation  he  uses  the  ordinary  Thompson's  sound, 
and  when  much  resistance  is  encountered  he  stretches  the 
stricture  rapidly  with  Thompson's  dilating  blades.  In  stric- 
tures of  the  spongy  portion  of  the  urethra,  when,  from  any 
cause,  slow  dilatation  is  undesirable,  he  practices  divulsion  by 
Holtz's  method,  and  also  internal  urethrotomy,  using  for  the 
latter  purpose  an  ordinary  Charriere's  instrument.  He  pre- 
fers urethrotoray  to  divulsion,  particularly  in  irritable  and 
resilient  strictures.  Strictures  at  or  near  the  meatus  he  di- 
vides. In  practicing  the  common  process  of  gradual  divul- 
sion, when  the  stricture  is  tight  and  the  opening  small  or 
tortuous,  he  usually  employs  whalebones  bougies  and  Gouley's 
tunnelled  catheters.  The  whalebone  he  makes  himself,  and 
they  are  very  much  finer  than  those  to  be  bought  in  the  shops, 
which,  nine  times  out  of  ten,  are  not  sufficiently  flexible,  and 
are  therefore  useless.  Dr.  Brinton  insists  with  great  empha 
sis  upon  the  permeability  of  all  strictures,  with  occasional 
exceptions,  i.  e.,  those  of  traumatic  origin.  In  difficult  cases 
the  passage  of  the  whalebone  is  a  work  demanding  great  dex- 
terity and  gentleness,  and,  according  to  this  surgeon's  teach- 
ings, cannot  be  confidently  anticipated  if  the  patient  has  been 
practiced  upon  the  same  day  with  instruments  of  larger 
diameter  and  with  rounded  points.  When  a  stricture  is  sus- 
pected, or  known  to  be  a  tight  one,  he  invariably  uses  first  tho 
whalebone  and  over  it  the  tunnelled  catheter,  deferring  to  a 
later  stage  of  dilatation,  instruments  flexible,  or  soft,  of  in- 
creased size. 

In  the  practice  of  the  Philadelphia  Hospital,  Dr.  Brinton 
deprecates  unnecessary  interference  with  the  urethra.  The 
patients  in  this  institution  are  paupers,  collected  from  the 
lowest  ranks  of  life,  with  constitutions  utterly  broken  down 


76*  Notes  of  Hospital  Practice. 

by  exposure  and  debauch.  In  his  judgment  the  results  ob- 
tained from  operations  upon  such  subjects  are  greatly  inferior 
in  point  of  success  to  those  which  attend  like  operations  in 
private  practice. 

SYPHILITIC  SORE  THKOAT. 

The  parts  are  kept  thoroughly  cleansed.  This  cleansing  ia 
performed  with  a  syringe,  brush  or  spray  douche.  The  water 
used  contains  some  of  the  chlorate  or  permanganate  of  potas- 
sium, or  some  carbolic  acid.  Local  medication  is  not  em- 
ployed unless  ulceration  has  set  in.  Occasionally  a  20-grain 
solution  of  the  nitrate  of  silver,  or  sulphate  of  copper  is.em- 
ployed.  In  making  these  applications  care  is  taken  to  cover 
the  whole  patch,  so  that  the  diseased  tissue  shall  be  completely 
destroyed. 

Where  Dr.  Cohen  desires  to  make  a  good  local  application, 
instead  of  a  camel's-hair  brush,  he  uses  a  broad  or  flat  paint 
brush,  so  that  one  sweep  of  the  brush  will  cover  a  space  half 
an  inch  wide.  In  this  way  the  whole  diseased  surface  can  be 
washed  by  one  motion. 

The  best  form  of  lunar  caustic  has  been  found  to  be  that 
which  comes  in  the  shape  of  a  lead  pencil.  This  contrivance 
enables  the  physician  to  confine  the  cauterization  strictly  to 
the  unhealthy  tissue.  When  an  application  is  made  to  the 
side  of  the  palate,  the  wood  is  cut  away  from  the  pencil  so  as 
to  leave  a  small  piece  of  the  caustic  exposed  laterally. 

The  constitutional  treatment  of  the  secondaiy  syphilitic 
sore  throat  consists  in  mercurialization,  and  of  the  tertiary  in 
iodization. 

When  perforation  is  threatened,  the  iodide  of  potassium  is 
given  in  doses  of  from  30  to  90  grains  every  three  or  four 
hours,  for  thirty-six  hours,  if  necessary,  or  until  a  change  for 
the  better  takes  place. 

In  giving  large  doses  of  the  iodide,  the  patient's  throat  ia 
carefully  watched  to  see  that  oedemu  of  the  larynx  does  not  occur. 


Surgical  and  Venereal  Diseases.  77 

If  the  patient  comes  in  in  such  a  late  stage  of  perforation 
that  the  uvula  is  found  to  be  suspended  from  its  base  by  only 
a  thin  shred  of  flesh,  Dr.  Cohen's  rule  is  to  let  it  alone  unless 
it  gives  rise  to  harassing  cough,  when  it  is  clipped  off  with  a 
pair  of  scissors.  If  this  necessity  does  not  occur,  the  strong 
probability  is  that  the  separated  parts  will  unite  again  so  soon 
as  the  system  is  thoroughly  under  the  influence  of  the  iodide 
of  potassium. 

With  regard  to  the  question  as  to  how  long  the  system 
should  be  kept  under  the  influence  of  anti-syphilitic  remedies, 
Dr.  Cohen's  rule  is  that  these  remedies  should  be  continued 
until  all  evidence  of  the  disease  has  ceased,  and  that  they 
should  even  then  be  kept  up  for  a  couple  of  months  longer, 
and  then  that  small  doses  should  be  taken  every  few  weeks, 
and  whenever  the  throat  shows  the  slightest  disposition  to  take 
on  specific  inflammatory  action. 

TEMPORARILY   IRREDUCIBLE   HERNIA. 

If  the  irreil  ucibility  is  due  to  the  distention  of  the  sac  by 
air,  or  by  faeces,  Dr.  Agnew  at  once  proceeds  to  attempt  to 
dislodge  the  sac's  contents.  The  patient  is  placed  upon  his 
back,  his  shoulders  elevated,  his  thighs  flexed  upon  the  ab- 
domen, and  gentle  compression  instituted  over  the  region  of 
the  tumor.  This  compression  is  made  with  great  care  and 
very  gradually.  If,  at  the  end  of  fifteen  minutes,  a  little 
yielding  is  felt  and  a  slight  gurgling  sound  hoard,  the  prog- 
nosis is  good.  If  this  gentle  compression  is  not  followed  by 
these  signs  it  is  stopped  at  once  and  something  else  tried.  In 
the  case  of  an  inguinal  hernia  some  leeches  are  placed  over 
the  course  of  the  spermatic  cord;  if  femoral,  they  are  put 
above  the  saphenous  opening,  and  a  cold  water  dressing 
applied. 

If  the  case  is  still  obstinate,  the  patient  is  kept  quiet  on  his 
back,  and  the  following  prescription  given : 


78  Notes  of  Hospital  Practice. 

B     Pulv.  opii gr.  j. 

Ext.  belladonna gr.  ss. 

Ext.  aloes, 

Pulv.  rhei aa   gr.  ij. 

M.  et  in  pil.    No.  iy. ;  divide. 
Sio. — One  pill  every  hour. 

The  cold  water  dressings  are  kept  over  the  part.  In  the 
course  of  eight  hours  an  injection  is  given.  In  cases  where 
the  stomach  will  retain  anything,  castor  oil  is  given  in  doses 
of  two  teaspoonfuls  every  two  or  three  hours,  as  a  cathartic. 

[Dr.  Chas.  Hunter  has  performed  Dr.  Dowell's  operation 
for  hernia  (strangulated)  in  a  number  of  cases  with  positive 
success.] 

A   UNIQUE   CASE   OF   INJURY   TO   THE   BRAIN. 

"  E.  A.  D.,  set.  40,  on  April  27th,  1879,  walked  into  the  hos- 
pital and  up  stairs.  The  top  of  his  head  was  in  a  horrible 
condition.  There  was  a  lacerated  wound  three  inches  long  by 
one  and  a  half  wide,  and  very  deep.  The  integument  had 
sloughed  or  been  torn  away,  the  bones  were  missing,  the  dura 
mater  was  exposed  and  sloughing,  and  the  brain  could  be 
seen  pulsating  in  the  foul  mass,  which  it  seemed  to  be  trying 
to  pump  out.  The  patient  was  perfectly  rational,  and  gave 
the  following  account  of  himself: 

He  was  first  officer  in  a  three-masted  schooner  sailing  from 
the  West  Indies  to  New  York  with  a  cargo  of  sugar.  He 
had  worked  very  hard  at  loading  the  vessel  in  the  heat,  and 
for  two  days  and  nights  after  sailing  for  home  he  was  con- 
stantly on  the  watch.  He  suddenly  became  ill,  and  conceived 
the  idea  that  the  captain  and  crew  were  going  to  murder  him 
and  throw  him  overboard.  To  frustrate  them  he  thought  he 
would  take  his  own  life,  and  tried  to  jump  overboard,  but  was 
prevented  from  doing  so.  On  the  fourth  day  out,  when  off 
Cape  Hatteras,  he  got  possession  of  an  axe  and  dealt  himself 
several  severe  blows  on  the  top  of  the  head  with  the  handle, 
fracturing  the  skull.  He  then,  witli  the  sharp  edge,  chopped 


Surgical  and  Venereal  Diseases.  79 

out  the  softened  mass,  and  picked  away  pieces  of  the  bones. 
After  this  he  got  better  and  returned  to  normal  consciousness. 
On  the  25th,  four  days  after  inflicting  the  injury,  the  vessel 
arrived  at  New  York.  The  patient  walked  to  the  cars  and 
came  to  Philadelphia. , 

He  said  he  was  a  temperate  man,  that  he  only  took  an 
occasional  drink,  and  that  he  was  not  in  delirium  tremens. 
His  appearance  certainly  did  not  indicate  a  man  of  intemper- 
ate habits.  His  story  was  so  unlikely  that  it  was  of  course 
doubted,  but  no  inquiry  elicited  iiy  other  statement,  and  he 
persisted  in  it  to  the  last,  bringing  no  accusation  against  any 
one — in  fact  volunteering  the  declaration  that  the  captain  and 
crew  were  the  best  he  had  ever  sailed  with. 

The  sloughs  were  partially  cleared  away,  several  small 
pieces  of  bone  were  removed,  cold  compresses  with  mild  anti- 
septics were  applied,  and  a  nourishing  diet  ordered. 

The  patient  was  in  the  third  story.  I  feared  he  might-1 
attempt  to  jump  from  the  window,  and  so  ordered  him  to  a 
private  room  in  the  basement.  He  remained  there  for  one 
night,  but  protested  against  it,  and  earnestly  requested  to  be 
sent  back  to  his  old  quarters,  saying  that  he  knew  perfectly 
well  what  he  was  about,  and  that  it  was  too  much  like  a 
prison  down  stairs.  His  request  was  complied  with,  and  there 
was  no  trouble. 

By  May  1st  more  serious  symptoms  set  in.  There  was- 
high  fever  and  a  quick  pulse.  The  temperature  was  1|° 
higher  on  the  right  side  than  upon  the  left.  This  side  was 
the  seat  of  spasmodic  twitchings  and  contractions,  and  by  the 
4th  it  became  completely  paralyzed.  A  hernia  cerebri  was 
also  beginning  in  the  wound,  and  there  was  some  stupor. 
There  was  no  facial  palsy.  On  the  5th  there  was  an  attack 
of  erysipelas,  from  which  the  patient  recovered  in  a  few  days. 
Discharges  had  in  the  meantime  been  thrown  off  freely  from 
the  wound,  and  on  the  7th  an  interesting  event  occurred.  Dr. 
Mcllwaine,  while  dressing  the  wound,  saw  the  end  of  a  piece 
af  bone  deep  down  in  its  anterior  part  and  to  the  right  side, 


80  Notes  of  Hospital  Practice. 

about  an  inch  in  front  of  the  coronal  suture.  This  and 
another  piece  he  removed.  These  were  pressing  upon  the 
right  hemispheres  in  this  position.  There  was  some  venous 
hemorrhage,  and  a  small  black  clot,  which  was  also  taken 
out.  The  pieces  were  respectively  £xj  an  inch  and  fxf  of 
an  inch  in  size.  They  had  been  actually  driven  down  and 
buried  under  the  sound  part  of  the  skull  by  the  force  of  the 
blows,  and  were  only  exposed  by  the  cleaning  up  of  the  wound. 
Almost  immediately  the  paraplegia  in  the  left  arm  was  re- 
lieved, and  by  the  next  dayfthat  in  the  leg  had  also  disappeared. 

The  stupor  was  gone.  The  patient  said  he  felt  more 
rational,  and  he  could  bring  his  will  to  bear  upon  any  de- 
sired movement,  although  he  was  weak. 

This  relief  proved,  however,  to  be  but  temporary.  From 
day  to  day  signs  of  brainxdisorganization  and  abscess  were  ap- 
parent. The  paralysis  returned,  at  first  more  manifest  on  the 
left  side,  but  before  death  it  became  general.  The  intelligence 
was  good  up  to  within  a  few  days  of  death,  as  rational  an- 
swers were  given  to  questions.  There  was  no  active  delirium. 
There  was  much  fever,  the  temperature  chart  showing  a  range 
from  as  low  as  98 J  on  the  19th  of  May  up  to  106£  on  the 
31st.  Control  over  the  bladder  and  bowels  was  lost.  On 
the  31st  of  May  there  was  entire  unconsciousness,  and  death 
took  place  at  2  p.  M.,  June  1st. 

Autopsy. — After  the  scalp  was  removed  numerous  linear 
chips  of  bone  were  found,  and  many  linear  scratches,  twenty- 
five  or  more,  which  were  made  with  a  sharp  instrument,  were 
upon  the  outer  faces  of  the  frontal  and  parietal  bones,  and  all 
were  in  a  parallel  line  with  the  opening  in  the  calvaria.  This 
was  3  inches  long  and  1  inch  wide.  One  inch  in  length  was 
taken  out  of  the  frontal  bone  and  the  rest  was  from  the  parie- 
tals.  There  was  an  abscess  leading  from  the  base  of  the  cere- 
bral hernia  to  the  corpus  callosum.  An  abscess  was  in  each 
hemisphere.  Pus  was  infiltrated  between  the  cerebrum  and 
cerebellum.  The  dura  mater  was  torn  and  thickened  near 
the  posterior  portion  of  the  wound,  and  here  also  there  was 


Surgical  and  Venereal  Diseases.  81 

abscess.  The  lateral  ventricles  were  filled  with  serum.  At 
the  bottom  of  the  longitudinal  fissure  there  was  a  piece  of 
bone  £  an  inch  long  and  4  lines  wido,  about  which  there  was 
an  abscess. — Dr.  Wm.  Hunt" 

EXTENSION   IN    FRACTURES   BELOW   THE   KNEE, 

Dr.  S.  W.  Gross  treats  in  this  way  :  The  foot  is  well  band- 
aged and  covered  with  turns  of  a  roller.  A  shingle  is  then 
cut  to  fit  the  shape  of  the  sole  and  fastened  to  the  foot  by  ad- 
hesive strips.  The  weight  is  attached  to  a  knotted  cord 
passed  through  the  centre  of  this  foot-piece.  Potts'  fracture 
is  treated  in  this  way,  after  first  bringing  the  inverted  foot  into 
its  normal  position  by  means  of  a  broad  adhesive  strip  run- 
ning from  the  inside  of  and  across  the  middle  of  the  sole,  well 
up  on  the  outside  of  the  leg 

FRACTURE   OF   THE   CLAVICLE. 

The  arm  is  flexed  and  bound  to  the  body.  A  silicate  of- 
sodium  dressing  is  then  applied  so  as  to  retain  it  in  position. 
A  pad  in  the  axilla  is  necessary  in  lean  subjects. — Dr.  J.  If. 
Brinton. 

INTRACAPSULAR    FRACTURES. 

Instead  of  extension  by  adhesive  strips  and  the  use  of'wmtl 
bags  to  keep  the  fractured  limb  in  position,  Dr.  S..AV.  Gross.- by 
placing  pillows  under  the  knee,  puts  the  leg  into  the  shape  of  a 
double  inclined  plane.  The  adhesive  strips  are  then  attached 
on  both  sides,  from  the  seat  of  the  fracture  to  the  knee,  and 
are  carried  from  that  point  straight  out  to  a  pulley  :md  weight 
at  the  foot  of  the  bed. 

COMPRESSION   OF   THE   BRAIN. 

The  treatment  employed  by  Dr.  R.  J.  Levis  consists  of 
r«»st  in  bed,  with  the  head  and  shoulders  slightly  elevated,  to- 


#2  Notes  of  Hospital  Practice. 

getlier  with  stimulating  injections  of  turpentine  and  water 
Tui-pentine  beaten  up  with  water  (for  it  is  not  soluble  in  it) 
and  thrown  into  the  bowel  with  a  syringe,  in  the  form  of  a 
mixture,  lias  been  found  to  make  a  veiy  good  stimulating  injec- 
tion. It  not  only  produces  a  stimulating  effect  upon  the  system, 
bul  causes  what  is  equally  desirable,  a  free  evacuation  of  the 
bowels.  In  addition  to  this,  an  active  mercurial  cathartic  is 
administered,  and  the  patient  is  placed  upon  full  doses  of  the 
bromide  of  potassium,  60  grains  of  this  drug  being  given  in 
tho  course  of  the  first  twelve  hours,  and  subsequently  reducing 
tho  dose  to  about  one-half.  In  dealing  with  a  patient  in  this 
condition,  it  is  always  borne  in  mind  that  if  deglutition  be 
impaired,  as  is  usually  the  case,  medicines  and  articles  of  food 
should  not  be  given  by  the  mouth,  but  rather  by  the  rectum, 
because  if  a  patient  cannot  swallow,  there  is  great  danger  that 
whatever  may  be  introduced  into  the  mouth  will  pass  down 
into  the  trachea  and  produce  strangulation.  For  the  same 
reason,  if  mucous  accumulates  in  the  trachea  and  bronchial 
tubes,  the  patient  is  inverted,  to  facilitate  its  discharge. 

• 

EPITHELIAL,   CANCER. 

The  treatment  pursued  by  Dr.  Richard  J.  Levis  consists  in 
the  destruction  of  the  cancerous  tissue  by  successive  applica- 
tions of  chromic  acid.  This  acid- destroys  by  rapid  oxidation. 
The  pure  acid  is  prepared  for  application  by  diluting  the 
crystals  just  enough  to  render  them  liquid,  so  as  to  permit  of 
icady  application  with  the  brush.  It  is  then  applied  to  the 
margin  of  the  cancerous  growth,  upon  all  sides,  and  the  appli- 
cation is  repeated  from  time  to  time,  as  the  case  may  demand. 
In  this  way  the  morbid  growth  is  gradually  encroached  upon. 

INGROWING   TOE-NAIL. 

Dr.  Charles  T.  Hunter's  plan  of  treating  this  condition, 
consists  in  introducing  .a  thin  layer  of  surgical  cotton  beneath 


Surgical  and  Venereal  Diseases.  83 

the  edge  and  extremity  of  the  offending  nail,  thereby  keeping 
the  sharp  edge  of  the  nail  separated  from  the  ulcer,  until  the 
latter  cicatrizes.  A  small  roll,  or  pledget,  of  cotton  is  placed 
along  the  lateral  margin  of  the  nail  so  as  to  keep  the  promi- 
nent granulations  pressed  away  from  the  nail.  The  dressing 
is  kept  in  place  by  a  film  of  collodion,  and  a  narrow  strip  of 
adhesive  plaster  wound  two  or  three  times  around  the  toe. 
Before  the  cotton  is  gently  pressed,  or  crowded  beneath  the 
depressed  nail-margin,  collodion  is  painted  over  the  surface 
of  the  ulcer,  in  order  that  the  granulations  may  be  com- 
pressed by  the  contractile  film  left  by  the  evaporation  of  the 
ether  contained  in  the  collodion. 

To  introduce  the  cotton,  Dr.  Hunter  uses  a  steel  probe  with 
one  end  hammered  quite  thin  (about  J  of  a  line  in  thickness,) 
and  slightly  curved  on  the  flat — the  curve  corresponding  to 
the  lateral  curve  of  the  nail.  The  other  extremity  of  the 
probe  is  likewise  flattened,  but  not  curved.  The  probe  used 
is  four  inches  long. 

ERYSIPELAS. 

Dr.  Samuel  D.  Gross  finds  the  best  local  wash  to  consist  in 
a  solution  of  the  acetate  of  lead,  (  5  ss  to  Oij.)  A  cloth, 
saturated  with  this  solution  is  placed  over  the  parts  and  cov- 
ered with  oiled  silk,  or  waxed  paper.  When  the  digestion  is 
impaired  calomel  is  administered,  and  followed  in  the  course 
of  six  hours  by  a  dose  of  castor  oil.  Quinia  and  the  tincture 
of  the  chloride  of  iron  are  always  administered  for  their  tonic 
effect.  If  there  is  much  circulatory  disturbance,  gtt.  ij  of  the 
tincture  of  the  root  of  aconite  are  given  every  four  hours. 
Great  attention  is  paid  to  the  ventilation  and  diet.  In  the 
phlegmonous  variety  the  best  local  treatment  has  been  found 
by  Dr.  Gross  to  consist  in  free  incisions.  In  every  instance 
the  patient  is  at  once  separated  from  the  other  patients,  and 
if  it  be  in  summer  he  is  quartered  in  a  tent,  outside  of  the 
main  building,  where  there  is  plenty  of  fresh  air  and  sunshine. 


84  Notes  of  Hospital  Practice. 

PARAPHIMOSK. 

In  mild  cases  Dr.  S.  D.  Gross  finds  that  the  swelling  can 
be  reduced  by  the  application  of  a  solution  of  the  acetate  of 
lead,  ( 1  ss  of  the  acetate  to  Oij  of  water,)  or  by  mercurial 
ointment.  When  the  infiltration  is  great,  the  reduction  of  the 
swelling  is  secured  in  the  following  manner :  The  penis  i.s 
grasped  behind  the  retracted  prepuce,  and  the  blood  is  gradu- 
ally forced  out  of  the  head  of  the  penis,  which  is  then  pushed 
back,  while  the  prepuce  is  pressed  forward.  When  reduction 
is  not  to  be  accomplished  by  this  compound  movement,  an 
incision  is  at  once  made  through  the  stricture  formed  by  the 
prepuce  with  a  bistoury.  In  all  cases  where  there  is  much 
infiltration,  incisions  are  made  into  the  infiltrated  part,  in 
order  to  allow  the  serum  to  escape.  The  penis,  in  this  dis- 
ease, is  always  so  placed  as  to  point  towards  the  umbilicus. 


THE  MEDICAL  AND  SURGICAL  DISEASES  OF 
WOMEN. 

PELVIC  PERITONITIS   AND   CELLULJTIS. 

If  the  attack  cannot  be  aborted,  the  treatment  is  taken  up 
regularly,  the  two  most  important  indications  being  (1)  to 
stop  the  pain,  and  (2)  to  prevent  the  formation  of  pus.  With 
these  ends  in  view  full  doses  of  opium  and  of  the  bromide  of 
potassium  are  given  together  with  from  thirty  to  forty  grains 
of  quinia  daily.  The  abdomen  is  painted  with  iodine  and 
covered  with  a  poultice.  If  the  woman  is  plethoric  the  mor- 
phia is  given  by  the  mouth  with  neutral  mixture  and  wine  of 
ipecac.  In  some  cases  tonics  are  demanded.  Occasionally  the 
application  of  belladonna  and  blue  ointment  locally  proves 
beneficial. 

If  the  attack  lasts  for  more  than  a  week  and  the  local  ten- 
derness increases,  the  hot- water  douche  is  applied  to  the  tender 
cervix  uteri.  It  is  at  this  stage  also  that  flying  blisters  are 
applied,  beginning  with  a  good-sized  blister  over  the  iliac  re- 
gion. In  some  cases  this  is  all  that  is  required.  When  the 
tumor  still  persists,  however,  another  blister  is  put  on  over  the 
womb,  and  then  another  over  the  other  side  of  the  abdomen, 
and  so  on  until  the  swelling  disappears  entirely. 

If  at  any  time  a  sudden  chill  supervene,  the  plan  followed 
is  to  begin  all  over  again  with  large  doses  of  quinia  and  of 
morphia. 

When  pus  has  formed  tonics  are  administered,  and  among 
them  iron  especially. 

In  the  later  stages  of  the  disease  muriate  of  ammonia  has 
been  found  to  be  a  very  excellent  remedy. 

The  following  prescription  is  that  usually  employed : 

85 


86  Notes  of  Hospital  Practice. 

Jjt     Mist,  glycyrrhizse  comp f|jvi. 

Ammonii  chloridi Jjij. 

Hydrarg.  chlo.  corrosivi gr.  i. 

Tinct.  aconiti  radicis gtt.  xxiv.    M. 

SiG. — A  tablespoonful  in  water  every  six  hours, 

If  pus  has  formed,  and  it  becomes  impossible  to  secure  its 
absorption  by  medicinal  means,  the  spot  is  found  where  the 
abscess  is  beginning  to  point,  and  an  incision  made  large 
enough  to  admit  of  a  free  drain  of  pus.  After  aspiration  the 
cavity  is  injected  with  a  solution  containing  one  part  of  iodine 
to  nine  parts  of  water,  or,  in  some  instances,  a  five  per  cent, 
solution  of  carbolic  acid  is  employed. — Dr.  Goodell. 

ANTEFLEXION  OF  THE    UTERUS. 

The  patient  was  a  servant-girl,  27  years  of  age,  with  a  his- 
tory of  menstrual  irregularities  extending  through  a  period  of 
seven  years.  Accompanying  the  flow  there  had  been  occasional 
suprapubic  pain.  Six  months  before  her  admission  to  the 
hospital  this  pain  had  become  constant,  and  she  had  been 
compelled  to  give  up  all  work.  She  was  obliged  to  pass  her 
water  twenty  or  thirty  times  a  day.  The  urine  was  examined, 
and  found  to  be  entirely  normal  in  all  respects. 

Vaginal  examination  showed  the  uterus  to  be  a  little  lower 
than  natural,  the  finger  encountering  the  fundus  in  the  ante- 
rior cul-de-sac.  Together  with  this  anteflexion  there  was 
some  catarrh  of  the  bladder,  while  the  woman  was  anaemic 
and  hysterical,  and  suffered  greatly  from  constipation. 

It  was  concluded  by  Dr.  J.  F.  Meigs  that  the  first  thing  to 
do  was  to  build  up  the  woman's  general  health.  Rest  in  bed 
was  enjoined ;  thrice  a  day  she  took  gr.  iv  of  the  ammonio- 
citrate  of  iron  with  gentian,  and  the  following  prescription 
was  employed,  viz. : 

R     Magnesii  sulphat £vj. 

Acid  sulph.  dil gij. 

Ferri  sulph gr.  xij. 

Quinise  sulph gr.  xij. 

Syrupi  zingiberis f.^j. 

Aquse q.  s.  ad  f 3  vi.      M 

8i(». — A  tablesnoonful  in  ice- water  thrice  dail  v. 


The  Medical  and  Surgical  Disease*  nf  Women.        87 

To  cure  the  anteflexion,  instead  of  introducing  a  pessary  it 
was  determined  to  persuade  the  woman  to  teach  her  bladder 
to  hold  gradually  more  and  more  urine.  It  was  reasoned  that 
when  the  bladder  could  hold  twelve  ounces  the  anteflexion 
would  be  largely  reduced. 


THE   VOMITING   OP   PREGNANCY. 

A  good  prescription  is,  viz. : 

R     Cerii  oxalat gr.  i. 

Ipecacuanhae gr.  i. 

Creasoti gtt.  ij.    M. 

SiG. — To  be  taken  every  hour. — Dr.  Gooddl. 

This  same  prescription  has  been  used  with  much  profit  at 
the  Episcopal  Hospital. 


H.EMATOMA    IN   DOUGLAS'   POUCH. 

Dr.  Goodell's  plan  is  to  keep  the  patient  perfectly  quiet  s^d 
administer  astringent  drinks,  such  as  sulphuric  acid  lemona»le, 
etc.  Opium  enough  is  given  to  lull  the  pain  and  keep  1  he 
patient  thoroughly  quiet.  For  a  number  of  hours  following 
the  attack,  but  a  very  slight  amount  of  nourishment  is  giv*-n. 
Stimulants  are  refrained  from,  and  the  patient  is  kept  as  It^w 
as  possible,  until  all  immediate  danger  from  peritonitis  has 
passed  away.  If  the  woman  is  married  her  vagina  is  pack-*! 
with  ice,  but  in  the  case  of  a  virgin,  where  the  hymen  »s 
intact,  the  ice  is  placed  over  the  abdomen  and  perinseum. 

PERIMETRITIS. 

The  first  thing  done  by  Dr.  Goodell  is  to  put  the  woman  to 
bed  and  keep  her  quiet.  Flying  blisters  are  then  applied 
over  the  abdomen.  A  mush  poultice  is  put  on  as  soon  as 
the  blister  begins  to  draw.  The  first  blister  is  placed  on  the 


88  Notes  of  Hospital  Practice. 

right  side  of  the  abdomen,  and  then,  in  the  course  of  a  few 
days,  another  is  applied  to  the  left  side,  and  then  one 
over  the  middle;  l/24  of  a  grain  of  the  bichloride  of  mercury, 
with  10  grains  of  the  muriate  of  ammonia,  are  given  three 
times  a  day  in  the  rnixtura  glycyrrhizae  composita.  A  pessary 
of  cotton  is  constructed  which  can  be  so  adjusted  as  to  hold 
the  womb  up.  This  cotton  is  dipped  in  a  solution  containing 
£  of  a  grain  of  morphia  to  the  drachm  of  glycerine.  The 
morphia  allays  the  pain  and  reduces  the  inflammation,  and 
the  glycerine  usually  sets  up  a  copious  watery  discharge  from 
the  vagina.  Iron  is  not  employed  until  late  in  the  progress 
of  the  disease. 

After  the  inflammation  is  subdued,  the  patient  is  put  upon 
the  following  mixture : 

R     Hydrarg.  chlor.  corros gr.  j. 

Liq.  chloridi  arsenitis f^88- 

Mist,  ferri  chloridi. 

Acid,  muriat.  dil aa    f^ij. 

Syrupi ff  iij. 

Aquse q.  8.  ad  f^vj.    M. 

Sio. — One  tablespoonful  after  each  meal. 

POST-PAETUM   HEMORRHAGE. 

The  management  of  post-partum  hemorrhage  is  divided  by 
Dr.  R.  A.  F.  Penrose  into  preventive  and  curative  treatment. 
First,  as  regards  preventive  measures.  If  the  woman  is  ple- 
thoric and  has  bled  profusely  at  former  labors,  saline  purga- 
tives and  diuretics  are  employed,  and  she  is  kept  upon  a  low 
diet  for  some  time  previous  to  confinement.  If  there  is  marked 
anaemia,  iron,  bitters,  stimulus,  and  plenty  of  good,  nourish- 
ing food  is  used.  If  the  labor  proves  long  and  tedious,  it  is 
hastened  by  the  careful  and  skillful  use  of  the  forceps.  If  it 
is  too  rapid,  on  the  other  hand,  the  endeavor  is  made  to  ren- 
der it  slower  by  anaesthetics,  etc.  As  soon  as  the  child  is 
born  ergot  is  given  freely,  and  all  external  means  of  causing 
contraction  are  brought  to  bear  upon  the  case. 


The  Medical  and  Surgicat  Diseases  of  Women.         89 

The  curative  treatment  consists  (1)  in  removing  the  placenta 
at  once,  in  administering  ergot,  and  in  placing  one  hand  in 
the  cavity  of  the  uterus  and  making  firm  pressure  over  the 
abdomen  with  the  other.  If  .these  fail,  (2)  a  cold  application 
is  at  once  made.  A  piece  of  ice  about  the  size  of  a  walnut,  is 
carried  right  up  into  the  cavity  of  the  womb.  If  the  ice  does 
any  good,  it  dogs  it  at  once.  If  the  patient  still  bleeds,  (3,) 
a  piece  of  rag  is  dipped  into  a  cup  of  vinegar  and  then  car- 
ried up  into  the  uterus  and  squeezed,  or  a  lemon  is  pared, 
gashed  in  numerous  places,  carried  up  into  the  womb  and 
squeezed.  The  (4)  last  alternative  consists  in  instituting  com- 
pression upon  the  large  vessels  at  the  posterior  part  of  the 
abdominal  cavity,  and  in  administering  a  good  dose  of  opium. 

When  the  hemorrhage  is  checked  ergot  is  given  freely,  and 
a  tight  binding  is  placed  over  the  lower  part  of  the  abdomen. 
A  napkin  is  placed  below  the  vulva  to  give  notice  of  any  re- 
turn of  hemorrhage.  The  patient's  head  is  placed  low  down 
by  removing  pillow  and  bolster.  If  there  is  a  marked  dis- 
position to  faintness,  the  feet  are  elevated. 

During  convalescence  the  circulation  is  stimulated  by  lauda- 
num, by  the  mouth,  or  morphia  hypodermically.  Alcohol  is 
given,  either  in  water  or  milk.  The  nerves  are  toned  up  by  Hoff- 
mann's anodyne,  or  by  the  sweet  spirits  of  nitre.  Plenty  of 
saline  food  is  given  with  milk.  The  rest  of  the  treatment 
consists  in  watching  the  patient  carefully  and  keeping  hei1 
quiet. 

At  the  Woman's  Hospital,  Dr.  Anna  E.  Broomall  controls 
post-parturn  hemorrhage  by  means  of  the  hot-water  douchf.. 
It  is  thus  administered :  the  largest  size  of  bed-pan  is  placed 
beneath  the  patient's  hips.  A  Davidson's  syringe  is  employed. 
The  water  used  is  brought  to  a  temperature  of  110°  Fahr., 
and  is  not  less  in  quantity  than  two  quarts.  A  higher  tem- 
perature is  not  well  tolerated,  and  a  lower  temperature  has 
been  found  to  be  ineffective.  The  amount  of  the  injection 
has  been  given  as  not  less  than  half  a  gallon,  but  the  rule  is 
to  continue  the  injection  until  the  return  stream  is  clear. 


90  Notes  of  Hospital  Practice. 

Care  is  taken  to  see  that  the  syringe  is  in  good  order,  and  that 
(he  air  is  thoroughly  forced  out  of  it  before  it  is  used.  A 
metallic  tube  six  inches  in  length  is  employed  instead  of  the 
vaginal  nozzle  which  comes  with  Davidson's  syringe,  and 
which  is  apt  to  act  as  a  medium  for  puerperal  infection.  Tho 
metallic  tube  is  inserted  through  the  internal  os  up  to  the 
fundus  of  the  womb.  While  the  operator's  right  hand  intro- 
duces the  tube,  the  left  hand  grasps  the  fundus  uteri  through 
the  abdominal  parietes.  The  continuance  and  the  frequency 
of  the  repetition  of  the  douche  depend  on  the  promptness  and 
permanence  of  the  uterine  contractions. 

This  same  method  of  treatment  has  been  employed  with 
great  success  by  Dr.  Albert  H.  Smith. 

ANEMIA   AND   CHLOROSIS. 

Basham's  iron  mixture,  with  the  addition  of  fractional 
doses  of  strychnia,  has  been  found  very  admirable  in  its 
effects.  There  are  so  many  different  recipes  for  making  this 
celebrated  mixture,  that  the  one  is  here  given  which  has 
proved  to  be  the  best  : 


R     Tinct.  ferri  chloridi 

Acid  acetic,  diluti  ...............................................  fjf  ss. 

Liquor,  ammoniae  acetat  ......................................  f£  iijss. 

Curacoae, 

Syrupi  simplicis  ...........................................  aa    f^j. 

Aquse  ......................................  ~  ............  q.  s.  ad  f§  viij.     M. 

SiO.  —  One  tablespoonful  after  each  meal. 

The  following  formula  makes  another  very  elegant  and 
generally  useful  preparation  of  iron  : 


R     Tinct.  ferri  chloridi  ............ 

Acid,  phosphoric!  diluti 

Spts.  limonis 

Syrupi  simplicis  ...........................  . 

Aquae  ......................................................  q.  s.  ad  f^  vj.       M 

Sio.  —  One  tablespoonful  after  each  meal. 


Tlie  Medical  and  Surgical  Diseases  of  Women.        91 

The  dilute  phosphoric  acid  is  added  both  because  it  is  a 
valuable  nerve-tonic,  and  because  it  has  the  property  of  dis- 
guising the  styptic  taste  of  the  iron ;  so  much  so  that  children 
readily  take  this  mixture. 

There  are  two  other  tonic  preparations  which  are  prescribed 
very  frequently  in  the  Hospital  of  the  University  of  Penn- 
sylvania, and  with  capital  results.  One  of  them  is  Blaud's 
pill,  which  Niemeyer  extols  so  very  highly  : 

R     Pulv.  ferri  sulphat.  exsiccat. 

Potass,  curb,  purse aa     3  ij. 

Syrupi q.  s. 

Ut  fiat  massa  dividenda  in  pilulas,  No.  xlviij. 

During  the  first  three  days  one  pill  is  to  be  taken  after  each 
meal.  On  the  fourth  day  four  pills  are  taken  during  the  day, 
on  the  fifth  day  five  pills,  on  the  sixth  day  six;  that  is  to  say, 
two  pills  after  each  meal.  For  three  days  more  six  pills  are 
taken  daily ;  then  the  dose  is  to  be  increased  by  one  pill  daily 
until  three  pills  are  taken  after  each  meal.  On  this  final 
dose  the  patient  is  kept  for  three  or  four  weeks  as  the  case 
may  be.  In  stubborn  cases  the  dose  has  been  increased  to  the 
number  of  five  pills  thrice  daily,  and  no  other  bad  effects  have 
followed  it  than  a  feeling  of  fullness  in  the  head.  This  im- 
munity is  probably  owing  to  the  conversion  of  the  iron  sul- 
phate into  a  carbonate. 

The  other  preparation  is  a  valuable  alterative  tonic : 

R     Hydrarg.  chloridi  corrosivi gr.  i. 

Liq.  arsenic!  chloridi f^sa- 

Tinct.  ferri  chloridi. 

Acid,  hydrochloric!  dil aa    f^iv. 

Syrupi  f£  iij. 

Aquae q.  s.  ad  fg  vj.       M 

SIG  — One  dessertspoonful  in  a  wineglassful  of  water  after  each  meal 

Anaemic  and  chlorotic  patients  fatten  and  thrive  wonderfully 
on  this  mixture.  Dr.  Goodell  calls  it  the  Mixture  of  Four 
Chlorides.  It  should  not  be  given  for  a  longer  period  than  two 
weeks  at  a  time. 


5)2  Notes  of  Hospital  Practice. 

The  following  tonic  pills  are  much  prescribed  at  the  Gynae- 
cological cliuic  of  the  Hospital  of  the  University  of  Penn- 
sylvania : 

R     Acid,  arseniosi. 

Strychnia  sulph aa    gr.  3*5 

Ext.  belladonna gr.  £ 

Cinchoniae  sulph gr.  jsa. 

Pil.  ferri  carb  gr.  ijss.     M 

Etft.  pil.,  No.j. 

R     Acid,  arseniosi gr.  -fa 

Cinchonise  sulph gr.  jss. 

Ferri  et  potass,  tart... gr.  ij.        M. 

Etft.  pil,  No.j. 

The  sulphate  of  cinchonia  in  these  pills  may  be  advantage- 
ously substituted  by  a  proportionate  dose  of  sulphate  of  quinia, 
the  former  being  used  simply  on  account  of  its  cheapness. 
One  pill  may  be  given  after  each  meal. 

THE   MENOPAUSE. 

The  diet  is  restricted  and  all  stimulating  foods  are  avoided, 
even  though  the  patient  may  feel  weak  and  indisposed  to  ex- 
ertion. Alcohol  and  fatty  foods  are  strictly  prohibited.  So, 
too,  are  butter,  meat  and  fried  foods.  What  is  allowed  is 
light  and  digestible.  Moral  suasion  has  been  found  to  be  of 
essential  importance.  The  change  of  life  through  which  she 
is  passing  is  explained  to  the  patient,  and  her  confidence  thus 
gained.  Exercise,  fresh  air,  sunlight,  gymnastic  exercises, 
bathing  and  horseback  riding  are  the  chief  hygienic  indica- 
tions. If  the  patient  is  feeble,  with  a  tendency  to  the  tubercu- 
lous diathesis,  care  is  had  that  she  is  not  placed  upon  an  ex- 
hausting treatment.  Where  the  liver  is  congested,  occasional 
doses  of  blue  pill — 3  to  5  grains  once  every  fourteen  days — 
are  prescribed.  If  calomel  is  not  borne,  Dr.  Pepper  gives 
Epsom  or  Rochelle  salts.  The  nervousness  is  quieted  by  doses 
of  the  bromides.  Assafcetida  and  valerian  have  also  been 
found  to  be  very  useful.  Excellent  results  have,  in  some 


The  Medical  and  Surgical  Diseases  of  Women.        l)f> 

cases,  followed  the  use  of  2-grain  doses  of  the  monobromide 
of  camphor,  given  every  two  hours  until  10  grains  have  been 
ingested.  The  symptoms  of  circulatory  disturbance  are  best 
combated  by  digitalis.  Where  plethora  exists,  veratrura 
viride  is  given. 

The  following  is  an  excellent  anti-spasmodic: 

R     Acid,  hydrocyan.  dil gtt.  ij. 

Sodae  bicarb gr.  v. 

Tinct.  valeriani 9  j. 

Zingiberis  syrupi Tr^x!. 

Aquae f 3  iij.    M 

Sio. — In  water,  thrice  daily. 

THE   DIAGNOSIS  OF   PREGNANCY. 

"A  married  woman  comes  to  the  clinic  to-day  desiring  to 
know  if  she  is  pregnant.  The  usual  signs  of  pregnancy  are 
known  to  you  all.  In  the  present  case,  the  woman  tells  me 
that  her  monthlies  have -been  regular  ever  since  her  marriage, 
but  that  she  has  increased  in  size,  has  felt  what  she  supposes 
are  foatal  movements,  and,  in  fact,  deems  herself  to  be  about 
eight  months  gone.  Upon  examination,  I  find  the  breasts 
unswollen,  and  without  the  areola  of  pregnancy  surrounding 
the  nipple.  The  regularity  of  the  menses  is  a  very  strong 
presumption  against  pregnancy,  but  I  shall  look  further.  By 
flexing  the  legs  upon  the  abdomen,  and  so  relaxing  the  recti 
muscles,  I  am  able,  with  one  finger  in  the  vagina  and  the 
other  hand  on  the  abdomen,  to  map  out  clearly  the  size  and 
position  of  the  womb.  It  is  of  the  usual  virginal  size, 
and  in  the  usual  position.  Let  me  call  your  attention 
to  a  sign  not  often  spoken  of  in  the  books,  viz.,  the  con- 
dition of  the  cervix.  My  finger  placed  upon  it  tells  me 
that  the  cervix  uteri  is  as  hard  and  as  unyielding  as  gristle. 
In  pregnancy,  even  in  the  earlier  mouths,  the  cervix  becomes 
soft  and  flaccid.  This  happens  almost  invariably,  and  the 
hardness  of  the  cervix  here  enables  me  to  say  with  much 
r,'onfidence,  that  I  do  not  think  the  woman  can  be  preg- 


y4  Notes  of  Hospital  Practice. 

riant.  She  may  possibly  be  in  the  first  or  second  week,  but  1 
consider  it  extremely  unlikely.  You  may  adopt  the  follow- 
ing general  rule  of  diagnosis  :  When  the  cervix  feels  as  hard 
as  the  tip  of  your  nose,  pregnancy  does  not  exist;  when  it 
feels  as  soft  as  your  lips,  the  womb  probably  contains  a  foetus. 
This  woman  has  had  no  morning  sickness,  and  her  breasts, 
upon  pressure,  yield  no  milk,  not  even  any  moisture.  Even 
early  in  pregnancy,  as  a  general  rule,  the  nipples  will  yield  a 
drop  or  two  of  milk,  when  squeezed.  Her  bowels  are  regular, 
and  she  experiences  no  difficulty  in  voiding  her  urine,  and  on 
the  other  hand,  no  tendency  to  too  frequent  micturition.  I  think 
that  the  results  of  my  examination  preclude  the  possibility  of 
pregnancy." — Dr.  Goodell. 

PUERPERAL,   FEVER. 

The  treatment  pursued  by  Dr.  Ellerslie  Wallace  is  that  of 
oleeding — bleeding  the  fever  out,  no  matter  whether  it  require 
the  loss  of  twelve  or  thirty-five  ounces  of  blood.  When  the  fever 
is  entirely  subdued,  the  patient  is  given  3  grains  of  opium — 
of  the  watery  extract  of  opium.  It  is  then  the  custom  to 
take  a  piece  of  flannel,  broad  enough  to  cover  the  distended 
belly,  and  after  squeezing  it  out  of  hot  water  and  rubbing 
some  oil  and  laudanum  well  into  it,  to  apply  it  to  the  disten- 
ded surface,  covering  it  with  a  bit  of  oiled  silk  or  carded  cot- 
ton, and  pinning  a  bandage  round  the  body  loosely  over  all. 

Together  with  the  first  dose  of  opium,  the  patient  is  given 
from  10  to  12  grains  of  calomel — this  to  re-establish  the 
secretions.  At  the  same  time  some  nourishment  is  adminis- 
tered, in  the  shape  of  a  little  milk  and  some  beef-tea,  or  a 
mouthful  or  two  of  some  delicate  broth. 

When  convalescence  begins  the  amount  of  opium  is  dimin- 
ished, and  of  broth  increased,  and  the  bowels  are  unloaded  by 
means  of  a  warm-water  enema.  This  for  puerperal  peritonitis. 

Puerperal  metritis  is  treated  by  leeches,  instead  of  venesec- 
tion, together  with  opium  and  calomel. 


Tlie  Medical  and  Surgical  Diseases  of  Women.        95 

Dr.  Goodell  treats  this  disease  by  intra-uterine  injections  of 
a  warm  2  per  cent,  solution  of  carbolic  acid.  Ten-grain  dose*- 
of  quinia  are  given  every  four  hours  until  marked  cincho- 
nism  is  produced.  Morphia  is  administered  in  doses  suffi- 
ciently large  to  relieve  pain.  The  whole  abdomen  is  painted 
with  the  compound  tincture  of  iodine  and  covered  with  a  large 
mush  poultice.  If  it  is  deemed  necessary  to  open  the  bowels, 
large  doses  of  calomel  are  used. 

DYSMENORRHCEA. 

Where  this  condition  is  due  to  stenosis  and  flexion,  Dr. 
Goodell  does  not  believe  in  incising  the  cervix  uteri,  as  some 
New  York  gynaecologists  advise,  but  finds  by  placing  the 
patient  under  ether  and  using  very  powerful  dilators,  whose 
blades  do  not  feather,  that  it  is  very  rarely  needful  to  incise. 
In  using  these  dilators,  which  have  no  shoulders,  he  first  in- 
serts the  instrument  right  up  to  the  fundus  of  the  womb,  and 
then  withdraws  it  half  an  inch  before  beginning  to  dilate. 

Another  favorite  method  consists  in  taking  some  pieces  of 
slippery  elm  bark,  whittling  them  down  to  the  size  of  matche*, 
tying  a  string  to  each  piece  and  packing  the  cervical  canal 
with  them.  The  only  danger  to  be  guarded  against  in  using 
these  slips,  is  that  of  pelvic  peritonitis  and  cellulitis. 

THE   DIAGNOSIS  OF   OVARIAN   CYST. 

"  Ovarian  cyst  is  distinguished  from  dropsy  in  the  following 
manner :  In  a  case  of  ascites,  the  abdomen,  when  the  patient 
is  placed  on  her  back,  is  flat  on  top  and  bulges  out  at  the 
sides.  Here  there  is  a  projection  on  top  and  not  so  much 
bulging  out  at  the  sides.  In  ascites,  the  intestines  float  up  to 
the  top,  and  we  get  resonance  upon  percussion.  In  this 
woman's  case,  both  superficial  and  deep  percussion  reveal 
only  flatness.  In  cases  of  ascites,  when  the  fluid  is  allowed 
to  settle,  there  is  usually  resonance  on  the  top  of  the  abdo- 


96  Notes  of  Hospital  Practice. 

men,  and  dense  flatness  at  the  sides.  Here  there  is  quite  ap- 
preciable resonance  at  the  sides.  Examination  of  the  exter- 
nal genitals,  vagina,  womb,  and  breasts,  which  have  withered, 
excludes  the  possibility  of  pregnancy.  There  is  one  most  cer- 
tain way  of  settling  the  question,  and  that  is  by  means  of  the 
aspirator.  The  fluid  of  ascites  is  straw-colored  and  limpid  ; 
that  of  a  monocyst  is  perfectly  clear  and  limpid,  like  spring 
water ;  that  of  a  holycyst  is  thick,  dark  and  turbid,  from  the 
presence  of  disintegrated  red  blood  corpuscles:  that  of  an 
oligocysfc,  which  I  suspect  this  to  be,  is  usually  of  a  milk- 
and-water,  or  of  a  light  brown  color.  I  should  not  think  of 
tapping  a  polycyst  unless  I  were  ready  to  proceed  at  once  to 
operate.  The  fluid  is  so  intensely  acrid  and  irritating  that 
the  escape  of  a  few  drops  into  the  peritoneal  cavity  might  set 
up  a  violent  peritonitis,  and  rapidly  destroy  life." — Dr.  Goodell. 

LACERATION   OF   THE   PERESTJSUM. 

Dr.  Goodell  advises  the  immediate  operation  which  he  has 
invariably  found  to  be  very  successful  in  incomplete  lacera- 
tions. In  complete  lacerations,  however,  it  has  not  proved  so 
successful  as  the  secondary  operation.  In  the  primary  opera- 
tion, in  order  that  the  sutures  may  be  most  accurately  put  in, 
he  recommends  that  ether  be  given,  and  that  a  sponge  be 
placed  high  up  in  the  vagina  so  as  to  stop  the  flow  of  the 
lochia,  which  embarrasses  the  operation.  The  stitches  are 
made  as  in  the  secondary  operation,  and  merely  twisted  to- 
gether. In  the  secondary  operation,  if  the  sphincte  ani  is 
involved,  he  always  imbeds  the  first  two  stitches.  On  the 
eighth  day  all  the  stitches  are  removed,  except  the  lowest. 
The  faeces  are  then  softened  by  an  injection  of  warm  sweet 
oil,  and  the  bowels  moved  twelve  hours  later  by  a  dose  of  an 
ounce  of  castor  oil,  aided,  if  necessary,  by  a-n  injection.  After 
the  bowels  have  been  emptied  the  remaining  stitch  is  removed. 

DP.  Albert  H.  Smith  uses  the  Baker-Brown  needle  for 
putting  in  the  stitches.  He  always  puts  the  first  stitch  in 


The  Medical  and  Surgical  Diseases  of  Women.        97 

above,  making  that  stitch  draw  thoroughly  together  the  mar- 
gins of  sound  tissue  above  the  laceration.  He  believes  in 
imbedding  the  wire  all  the  way  round  in  the  tissues,  so  that 
when  the  ends  of  wire  are  drawn  together  there  is  no  pocket 
left  behind  the  stitches.  He  always  tightens  the  highest  stitch 
first,  thus  protecting  the  tissues  below  from  the  flow  of  blood. 

ABORTION. 

"  The  treatment  divides  itself  into  two  heads :  the  prevent- 
ive and  curative  treatment.  The  preventive  treatment  is  that 
by  means  of  which  we  prevent  the  repetition  of  abortion. 
Here  a  knowledge  of  all  the  causes  is  indispensable.  If 
plethora,  anaemia,  or  nervous  irritability  exist,  they  should  be 
modified  or  removed.  If  there  is  syphilis  in  either  of  the 
parents,  they  must  undergo  a  prolonged  anti-syphilitic  and 
tonic  treatment.  This  treatment  must  be  steadily  pursued  for 
several  years.  Where  the  abortion  is  due  to  any  local  dis- 
order, such  as  chronic  eudometritis,  hypertrophy,  prolapse, 
retroflexiou,  or  erosion  of  the  womb,  the  patient  must  be 
placed  upon  a  steady  course  of  treatment  for  the  removal  of 
these  causes.  Suppose,  however,  that  we  are  called  in  to  pre- 
vent the  occurrence  of  a  threatened  abortion,  what  shall  be 
done?  If  a  syphilitic  mother  become  pregnant,  she  must  be 
subjected  to  a  mercurial  treatment  and  the  local  condition 
thus  modified.  If  the  ovum  be  already  diseased,  it  will  be 
impossible  to  prevent  abortion.  Indeed,  under  such  circum- 
stances, abortion  would  be  a  most  fortunate  circumstance,  and 
on  no  condition  should  we  attempt  to  balk  nature  in  such  a 
case. 

The  first  question  we  should  ask  ourselves  in  all  cases  of 
threatened  abortion,  is:  Why  is  it  threatened?  Upon  the 
answer  to  this  question  depends  all  our  treatment.  If  the 
ovum  be  diseased  or  dead,  do  not  try  to  prevent  the  abortion. 
The  family  history  will  enable  you  to  determine  whether  the 
o^uin  be  diseased  ;  if  the  product  be  dead,  you  will  have  the 


98  Notes  of  Hospital  Practice. 

signs  of  death  in  utero.     Suppose,  however,  that  the  product 
is  not  dead  and  not  diseased,  shall  the  abortion  be  prevented  ? 
The  next  question  you  must  ask  is :  Can  I  prevent  it  ?     The 
embryo  may  be  so  far  expelled  that  it  would  be  worse  than 
useless  to  interfere.     The  answer  to  this  question  depends  on 
the  dilatation  of  the  os  and  the  amount  of  hemorrhage.     If 
the  hemorrhage  has  been  large,  and  the  amount  of  blood  lost 
considerable,  the  probability  is  that  the  utero-placental  con- 
nections are  so  separated  that  abortion  must  ensue.     Should  a 
vaginal  examination  show  the  os  uteri  to  be  well  dilated,  and 
the  membranes  bulging,  matters  have  gone  so  far  that  you 
cannot  hope  to  prevent  abortion,  and  therefore  should  assist  it. 
There  are  various  remedies  for  the  hemorrhage.     A  drachm 
of  the  fluid  extract  of  ergot  may  be  given  every  three  or  four 
hours.     I  prefer  the  old  wine  of  ergot  given  in  doses  of  2 
drachms  every  hour  or  so.     In  addition  to  the  ergot,  the 
books  tell  you  to  apply  cold  cloths,  ice,  and  vinegar  to  the 
abdomen,  and  to  give  gallic  and  tannic  acid,  or  acetate  of  lead, 
internally.     I  don't  believe  in  any  of  these  remedies.     They 
are  not  half  direct  enough  for  me.     If  ergot  does  not  control 
the  bleeding,  the  next  best  thing  you  can  do  will  be  to  tampon 
the  vagina.     A  tampon  acts  in  two  ways:  (1)  it  plugs  the 
vagina ;  and  (2)  it  stimulates  the  uterus  to  increased  efforts. 
Never,  however,  put  in  a  tampon  unless  you  have  given  up 
all  hopes  of  preventing  the  abortion.     If  you  don't  happen 
to  have  sponge-tents,  tear  up  any  napkin  or  piece  of  cloth  that 
comes  to  hand  and  plug  up  the  vagina.     Sometimes  I  have 
had  most  excellent  results  from  tamponing  the  mouth  of  the 
uterus  with  a  sponge-tent  or  laminaria. 

Now,  as  regards  the  curative  treatment.  If  abortion  occur 
during  the  second  or  third  month,  strive  to  secure  a  complete 
evacuation  of  the  uterus.  Otherwise  the  placenta  will  remain 
behind,  and,  becoming  detached  in  the  course  of  a  day  or  so, 
will  give  rise  to  very  serious  hemorrhage.  If  the  abortion 
occur  in  the  fourth,  fifth,  sixth  or  seventh  months,  the  mem- 
branes may  be  ruptured  without  danger  if  the  hemorrhage 


The  Medical  and  Surgical  Diseases  of  Women.        99 

proves  excessive.  When  the  child  has  been  expelled,  intro- 
duce your  finger  into  the  cavity  of  the  uterus,  and  feel  for  the 
afterbirth.  If  it  still  remains  in  the  cavity,  it  must  be  re- 
moved at  all  hazards.  Have  the  woman  brought  to  the  edge 
of  the  bed,  place  one  hand  upon  the  abdomen,  and  insert  a 
finger  of  the  other  hand  into  the  uterus.  Press  the  uterus 
well  down  upon  your  finger  inserted  into  it,  and  scrape  away 
until  you  have  removed  all  the  afterbirth.  Never  leave  this 
work  to  nature,  but  see  to  it  yourself  at  once.  Where  the 
placenta  and  membranes  cannot  be  removed  by  the  finger, 
various  instruments  have  been  devised  for  seizing  them  and 
bringing  them  out.  Hodge's  modification  of  Everett's  bullet 
forceps  is  an  entire  failure,  for  the  simple  reason  that  you 
can't  hold  on  to  any  foreign  body  after  you  have  seized  it 
with  this  instrument.  Dewees'  hook  is  not  open  to  this  ob- 
jection, but  it  is  so  sharp  that  it  might  do  much  injury.  The 
only  instrument  that  has  proved  efficient  is  this  species  of 
duck-bill  forceps  which  I  now  show  you.  I  defy  anything 
to  get  away  which  has  once  been  caught  by  this  instrument. 
If  the  placenta  and  membranes  have  begun  to  putrefy  when 
you  remove  them,  wash  out  the  cavity  thoroughly  with  some 
antiseptic  injection. 

Suppose  that  there  is  a  hope  of  preventing  abortion,  what 
must  you  do  ?  Put  the  woman  to  bed  and  give  her  2  grains 
of  opium  by  the  rectum.  Or  else  you  may  use  a  rectal  sup- 
pository containing  £  a  grain  of  the  extract  of  belladonna, 
and  1  grain  of  the  watery  extract  of  opium.  Opium  may  be 
given  hypodermically  where  the  case  is  an  urgent  one.  The 
bromides,  too,  should  be  freely  administered  in  doses  of  from 
25  grains  up  to  a  drachm.  When  the  symptoms  are  very 
acute,  ether  or  chloroform  may  be  inhaled.  Occasionally, 
where  the  woman  is  plethoric,  from  six  to  eight  ounces  of 
blood  should  be  taken  from  the  groin  by  leeches,  or  from  the 
arm  by  venesection.  Dry  cups  or  mustard  plasters  may  also 
be  applied  to  the  sacrum. 

When  abortion  takes  place,  the  symptoms  will  generally  dis- 


100  Notes  of  Hospital  Practice. 

appear.  There  willl  be,  perhaps,  a  lochial  discharge  for  a 
day  or  two.  You  must  now  employ  the  after-treatment  for 
labor  at  term.  Keep  the  woman  in  bed  for  two  weeks  or 
more.  Regulate  her  bowels  by  mild  saline  laxatives;  do  not 
use  enemata  at  this  time.  Be  careful,  also,  not  to  feed  the 
patient  too  highly.  Do  not  allow  any  meat  for  the  first  week. 
Ergot  should  be  given  steadily  to  promote  the  proper  sub- 
involution  of  the  uterus.  When  the  patient  gets  up,  put  her 
on  a  tonic  treatment,  and  impress  it  upon  her  that  she  is  still  an 
invalid,  and  must  take  no  violent  exercise.  At  her  next  men- 
strual period  the  flow  will  probably  be  excessive.  This  should 
be  treated  by  rest  and  by  saline  laxations.  The  vagina  should 
be  well  cleansed  with  astringent  solutions,  and  ergot,  gallic 
acid,  and  cinnamon  tea  administered." — Dr.  R.  A.  F.  Penrose. 

TREATMENT  OF  THE   FUNIS. 

As  soon  as  the  child  cries  lustily  Dr.  Goodell  cuts  the  cord, 
and  the  umbilical  portion  being  firmly  held  by  the  thumb 
and  forefinger,  the  free  end  is  "  stripped  "  of  Wharton's  jelly 
and  of  any  blood  that  may  remain  in  it.  Any  blisters  of 
Wharton's  jelly  which  remain  unemptied  after  this  "strip- 
ping," are  nicked  and  squeezed  out.  After  the  removal  of 
the  pressure  of  the  thumb  and  forefinger,  all  bleeding  usually 
ceases,  and  then  the  cord  is  tied.  No  subsequent  dressing  is 
thereafter  used,  for  the  cord  rapidly  dries  up  without  smell, 
and  drops  off  without  leaving  a  sore  behind. 

GATHERED   BREASTS. 

When  an  abscess  forms  in  the  mammary  glands,  Dr. 
Goodell  practices  an  early  incision.  If  the  pus  lies  deep,  or 
is  lodged  behind  the  gland,  a  cutaneous  incision  is  first  made, 
a  grooved  director  is  pushed  into  the  abscess  and  the  opening 
is  enlarged  by  the  uterine  dilator.  The  breast  is  then  tightly 
strapped  with  adhesive  plaster  and  treated  by  a  dry  compress 


The  Medical  and  Surgical  Diseases  of  Women.      101 

of  oakum.  Should  the  abscess  show  symptoms  of  becoming 
chronic,  its  walls  are  overstretched  by  an  injection  of  a  3  per 
cent,  solution  of  carbolic  acid.  This  overdistension  is  prac- 
ticed in  order  that  the  acid  may  reach  every  nook  and  cranny 
of  the  purulent  cavity. 

OVARIOTOMY. 

Dr.  Goodell  invariably  adopts  the  following  procedure :  A 
5  per  cent,  solution  of  carbolic  acid  is  used  in  the  spray,  and 
all  the  instruments  and  sponges  are  immersed  in  a  solution  of 
the  same  strength.  The  pedicle  is  treated  by  the  intra-peri- 
toneal  method,  being  transfixed,  tied  and  dropped  within  the 
abdominal  cavity.  The  peritoneum  is  always  included  in  the 
stitches  which  close  the  abdominal  wound.  All  obstinate 
bleeding  points  are  tied  with  a  gut  ligature,  but  the  pedicle 
itself  is  secured  by  fine  carbolized  silk.  In  three  cases  where 
there  were  numerous  adhesions  the  glass  drainage-tube  was 
employed.  The  dressing  consists  merely  of  salicylated  cotton, 
held  in  place  by  adhesive  straps,  the  whole  secured  by  an 
elastic  flannel  binder.  Dr.  Goodell  prefers  this  dry  form  of 
dressing  to  Lister's  wet  dressing.  The  after-treatment  con- 
sists of  opium  enough  to  allay  pain,  and  in  one  tablespoonful 
of  milk  combined  with  lime-water,  given  every  two  hours  for 
the  first  forty-eight  hours.  As  soon  as  wind  escapes  from  the 
bowels,  the  supply  of  food  is  increased. 

[The  patients  are  prepared  for  the  operation  by  a  soap-bath 
on  the  previous  evening,  and  by  the  administration  of  1  grain 
of  opium  at  bedtime.  Dr.  Goodell  always  operates  at  the 
hour  of  11  A.  M.,  as  being  the  time  at  which  the  vital  forces 
are  at  their  best.]  When  high  temperature  ensues,  it  is  re- 
duced by  the  ice-cap,  which  has  been  found  to  act  very  effi- 
ciently. 

SORE   NIPPLES. 

Chapped  nipples  are  treated  either  by  a  20-grain  to  1  drachm 
to  the  ounce  solution  of  the  glycerole  of  the  nitrate  of  lead,  or 


102  Notes  of  Hospital  Practice. 

by  a  mixture  of  2  drachms  of  iodoform  to  the  ounce  of  the 
balsam  of  Peru.  The  balsam  is  used  because  it  disguises  the 
smell  of  the  iodoform. — Dr.  Ooodell. 


PLACENTA  PR.EVIA. 

Abnormal  discharges  of  blood  from  the  womb  as  early  as 
the  sixth  month  of  pregnancy,  are  treated  by  putting  the 
patient  to  bed,  keeping  her  quiet  and  administering  from  gr. 
J  to  gr.  f  of  opium,  and  gr.  ij  to  iij  of  sugar  of  lead  in  f  §  ss. 
of  the  infusion  of  rose.  But  slight  trouble  is  experienced  in 
controlling  hemorrhage  until  the  neck  of  the  womb  begins  to 
dilate  in  earnest,  and  in  so  doing  tears  the  placenta  loose  from 
the  uterine  sinuses.  When  this  occurs  the  only  effective 
treatment  has  been  found  by  Dr.  Wallace  to  consist  in  the 
immediate  tamponing  of  the  vagina  with  sponge  tents.  Ca- 
thartics are  not  thought  of,  even  if  the  rectum  be  overloaded. 
The  tampon  is  not  on  any  account  removed  until  it  begins  to 
protrude  from  the  vagina,  and  when  it  cannot  be  pushed  back, 
though  much  force  be  expended  in  the  effort.  The  minute 
the  first  sponges  are  taken  out  their  places  are  supplied  by 
fresh  ones.  When,  in  due  course  of  time,  the  os  uteri  is  found 
to  have  expanded  sufficiently,  the  hand  is  greased  well,  passed 
far  up  into  the  uterus — forearm  and  wrist  acting  as  tampons — 
as  much  of  the  placenta  is  separated  as  may  be  necessary,  and 
the  child  is  turned  and  delivered  with  the  greatest  possible 
speed.  The  moment  the  child  is  born  the  placenta  is  removed 
by  the  hand,  and  the  uterus  is  made  to  contract  completely  by 
means  of  ice,  pressure,  ergot,  etc.,  and  a  bandage  is  firmly 
applied  round  the  patient's  abdomen. 

THE   DIAGNOSIS   OF  CONGENITAL   SYPHILIS. 

Dr.  Goodell  says  that  congenital  syphilis  may  appear  either 
before  or  after  birth.  The  labor  is  usually  premature,  and 
the  first  symptom  of  the  disease  is  the  hoarse  cry  to  which  the 


The  Medical  and  Surgical  Diseases  of  Women.      103 

child  gives  utterance.  The  bull®  soon  show  themselves. 
The  disease  in  uteri  takes  the  form  of  placentitis,  the  exuda- 
tion presses  the  blood  out  of  the  small  capillaries  and  so 
gradually  starves  the  production  of  conception,  or  there  may 
be  a  gummy  tumor  or  a  fatty  degeneration  of  the  placenta,  so 
causing  premature  labor.  In  some  cases  the  labor  is  precipi- 
tated by  atheroma  of  the  vessels  of  the  cord. 

The  child  gives  utterance  to  the  hoarse  cry  because  there 
are  already  syphilitic  ulcers  on  the  mucous  membrane  of  its 
throat  and  air-tubes.  Such  children  are  always  puny  and 
sickly  looking.  The  bullae  appear  in  the  course  of  a  few 
hours  after  the  birth,  and  are  visible  on  either  the  scrotum, 
hands,  or  feet. 

If  the  disease  does  not  reveal  itself  at  birth,  it  usually  ap- 
pears some  time  between  the  second  week  and  third  month 
after  birth.  The  first  symptom  is  excessive  crying  of  the 
child  at  night.  This  crying  is  caused  by  the  incipient  bone 
disease — pains  in  the  bones.  Its  cry,  too,  is  muffled  and 
hoarse.  The  next  symptom  is  the  snuffles ;  the  child's  nose  is 
all  stopped  up — a  scalding  coryza  comes  on.  Then  the  child 
grows  wizened  and  thin,  and  its  skin  lies  all  in  rolls  and 
wrinkles,  and  is  more  like  parchment  in  consistency  than  skin. 
The  so-called  copper  maculae  show  themselves,  or  the  com- 
plexion gradually  assumes  a  coffee-and-milk  hue.  Then  the 
eruption  comes  out  all  over  the  body,  and  stamps  the  case  in- 
disputably as  one  of  syphilis. 

In  some  instances  it  is  very  hard  to  find  out  whether  the 
mother  has  the  disease  herself,  or  whether  the  father  has  been 
the  only  instrument  of  innoculation.  In  this  connection  the 
curious  fact  has  often  been  noted  that  an  apparently  unaffected 
mother  can  nurse  her  syphilitic  child  with  impunity,  whereas 
the  child  is  sure  to  communicate  the  disease  to  a  healthy  wet- 
nurse.  Should  a  syphilitic  child  be  knowingly  allowed  to 
draw  its  sustenance  from  a  wet-nurse,  and  the  nurse  to  be  so 
innoculated,  she  has  just  grounds  for  an  action  at  law  against 
the  parents  of  the  child. 


104  Notes  of  Hospital  Practice. 

Treatment  is  generally  hopeless.  It  is  a  wise  law  of  nature 
which  sentences  all  such  vitiated  and  diseased  products  to 
early  death.  Of  course  all  the  physician  can  do  is  to  subject 
the  child  to  a  brisk  mercurial  treatment. 


HABITUAL  CONSTIPATION   IN  THE   FEMALE,  WITH   FISSURES 
OF   THE   RECTUM. 

Dr.  Goodell  cures  fissures  of  the  rectum  by  over-stretching 
the  sphincter  ani.  To  do  this  he  inserts  his  two  thumbs  into 
the  rectum  and  then  pulls  them  apart  until  either  the  sphinc- 
ter begins  to  yield,  or  he  can  feel  the  rami  of  the  ischia  on 
each  side.  To  do  this  requires  the  exercise  of  considerable 
strength. 

As  regards  after-treatment,  the  patient  is  taught  to  go  to 
stool  regularly  every  day,  and  to  eat  certain  kinds  of  food 
only.  For  medicine  the  following  prescription  is  given : 

R     Ext.  colocynth.  comp gr.  ij. 

Pu'lv.  rhei gr.  j. 

Ext.  belladonnas gr.  J 

Ext.  hyoscyami. gr.  ss.   M 

Et  in  pil.,  No.  1 ;  divide. 

Sio. — To  be  taken  at  bed-time. 

In  some  cases  1/20  of  a  grain  of  strychnia  is  added  to  the 
above  with  advantage. 

AMENORRHCEA. 

In  amenorrhoea  from  anaemia  and  chlorosis,  Blaud's  pills 
are  prescribed.  (See  jLncemia  and  Chlorosis.} 

To  counteract  the  possible  costive  effect  of  the  sulphate  of 
iron  in  these  pills,  Dr.  Goodell  advises  the  following  aperient 
mixture :  the  pulvis  glycyrrhizse  compositus  of  the  Prussian 
Pharmacopoeia,  upon  which  he  keeps  patients  for  months  and 
always  with  benefit. 


The  Medical  and  Surgical  Diseases  of  Women.      105 

R     Pulv.  glycyrrh.  rad. 

Pulv.  sennse  ...................................................  aa     3  ss. 

Sulphuris  sublim. 

Pulv.  fceniculi  ................................................  aa     !^ij. 

Sacchar.  purif.  ......................................................  gjsa.    M. 

SIG.  —  One  teaspoonfol  in  half  a  cupful  of  water  at  bed-time. 

Or  the  following  : 

R     Ext.  colocynth  comp  .............................................  gr.  ij. 

Ext.  belladonnas  ...................................................  gr.  J 

Ext.  gentianie  ......................................................  gr.  j. 

Ol.  carui  ............  .  .....  .  ..........................................  gtt.  ss.   M. 

Et  ft.  pil.,  No.  j. 

Sio.  —  To  be  taken  at  bed-time. 

Where  the  disease  is  due  to  torpidity  of  the  ovaries  this 
prescription  is  used  by  Dr.  Penrose  : 

R     Ex.  aloes  ............................................................  3J. 

Ferri  sulphat.  exsic  ..............................................  ^ij. 

Assafcetidse  ........................  ................................  ^iv.      M. 

Sio.  —  One  pill  after  each  meal. 

This  number  to  be  gradually  increased  to  2  and  then  to  3 
pills  after  each  meal.  If  the  bowels  are  at  any  time  over- 
affected  a  return  is  made  to  the  initial  dose. 

Another  excellent  prescription  used  by  Dr.  Goodell  is  the 
following  : 


R     Tr.  ergots 

Decoct,  aloes  comp  .......  .  .................  „  .........  q.  s.  ad  f^viij.  M. 

SlO.  —  Two  tablespconfuls,  twice  daily. 


CARUNCLE  OP  THE  UEETHBA. 

In  timid  women,  who  refuse  to  submit  to  an  operation,  Dr. 
Goodell  either  mummifies  the  growth  with  crystallized  carbolic 
acid  melted  down  by  heat,  or  destroys  it  by  applications  of 
chromic  acid,  made  with  the  utmost  care  by  means  of  a  match 
whittled  down  to  a  point,  the  excess  of  acid  being  afterwards 
neutralized  by  injections  of  a  strong  solution  of  the  bicarbon- 
ate of  sodium.  If  an  operation  is  permitted,  he  cuts  off  the 


106  Notes  of  Hospital  Practice. 

growth  with  a  pair  of  scissors  curved  on  the  flat,  and  sears  the 
wound  with  a  hot  wire,  or  with  Paquelin's  Thermo- Caviere. 
He  advises  the  use  of  an  alcohol  lamp  for  heating  the  wire, 
because  when  an  ordinary  light  is  used  the  impression  upon 
the  operator's  retina,  made  by  the  bright  flame,  so  obscures 
his  vision  that  the  cauterizing  apparatus  grows  cool  before  he 
can  clearly  see  the  point  where  the  application  is  to  be  made. 
He  hastens  the  healing  of  the  cauterized  surface  by  occasional 
applications  of  carbolic  acid,  or  by  dusting  it  with  iodoform. 

CANCER  OP  THE  CERVIX  UTERI. 

Whenever  practicable  the  whole  cervix  is  removed,  by 
either  the  hot  or  the  cold  wire.  If  this  cannot  be  done,  Dr. 
Goodell  removes  the  malignant  growth  by  scraping  or  by  the 
gouge  forceps,  and  the  surface  is  then  charred  by  the  thermo- 
cautery.  This  radical  treatment  is  reinforced  by  subsequent 
applications  of  the  ethylate  of  sodium.  In  these  operations 
upon  the  cervix  he  finds  injections  of  ordinary  vinegar  to  be 
an  excellent  means  of  controlling  any  embarrassing  bleeding. 
By  these  means  he  has  succeeded  in  curing  several  cases. 

CYSTITIS   IN   THE   FEMALE. 

Transient  cystitis,  dependent  upon  obscure  causes,  Dr. 
Goodell  treats  by  rectal  suppositories,  containing  1  grain  each 
of  the  aqueous  extract  of  opium,  and  of  the  extract  of  bella- 
donna. Hysterical  cases  generally  yield  to  massage  and  elec- 
tricity. In  obstinate  cases  of  bladder  trouble  Dr.  Goodell 
warmly  advocates  the  dilatation  of  the  urethra  throughout  its 
whole  length  by  the  introduction  of  the  forefinger.  In  the 
therapeutical  treatment  of  this  troublesome  disorder,  atropia 
nas  been  found  to  be  the  most  efficient  remedy.  It  may  be 
combined  with  alkalies  or  acids,  according  to  the  condition  of 
the  urine.  Injections  of  a  2-grain  solution  of  quinia  into  the 


The  Medical  and  Surgical  Diseases  of  Women.      107 

bladder,  together  with  large  doses  of  the  same  drug  by  the 
mouth,  will  often  improve  the  condition  of  the  patient.  In 
very  bad  cases  the  most  efficient  injection,  perhaps,  is  one  of 
the  nitrate  of  silver,  beginning  with  a  weak  solution  and  in- 
creasing its  strength  daily,  until  30  grains  to  the  ounce  if 
reached.  These  strong  solutions  should  not  remain  in  the 
bladder  longer  than  ten  or  fifteen  seconds.  All  malpositions 
of  the  womb  must  of  course  be  rectified,  especially  if  they  have 
any  bearing  upon  the  disease. 


CONICAL   CERVIX  UTERI. 

This  condition  is  treated  either  by  forcible  dilitation  with  a 
strong  uterine  dilator,  or  by  lateral  section  with  a  hysterotome. 
If  the  cervix  is  sickle-shaped,  Dr.  Goodell  performs  the  sec- 
tion of  the  posterior  lip.  The  subsequent  treatment  consists 
in  such  local  management  as  tends  to  keep  the  parts  from 
closing  up. 

PROLAPSE  OF  THE  OVARIES 

is  best  managed  by  the  knee  breast  posture,  and  by  the 
administration  of  such  alteratives  as  tend  to  lessen  the  con- 
gestion of  these  organs.  Among  these,  Dr.  Goodell  deems 
the  best  to  be  the  chloride  of  ammonium  in  combination  with 
the  bichloride  of  mercury.  Sometimes,  however,  large  doses 
of  the  bromides  act  very  happily.  He  considers  this  disloca- 
tion to  be  due  in  a  great  measure  to  the  congestion  of  the 
sexual  organs,  consequent  upon  the  use  of  measures  to  pre- 
vent conception,  or  from  masturbation.  He  finds  that  pes- 
saries are  rarely  useful  in  this  distressing  condition.  But 
among  them  he  thinks  Cutter's  bulb  pessary  to  be  the  best. 
He  considers  prolapsed  ovaries  to  be  a  very  frequently  over- 
looked cause  of  many  pelvic  aches  and  pains,  which  are  attri- 
buted very  generally  to  the  womb  alone. 


108  Notes  of  Hospital  Practice. 

CLOSURE    OF  THE   VULVA    FOR  VESICO- VAGINAL     FISTULA. 

In  curable  cases  of  vesico-vaginal  fistula,  in  which  the  urethra 
has  been  destroyed,  Dr.  Goodell  has  twice  succeeded  in  wholly 
relieving  the  patient. '  In  one  case  this  was  done,  by  making  an 
artificial  recto-vaginal  fistula,  and  in  the  other  by  leaving  an 
already  vesico-vaginal  fistula  intact,  and  in  then  closing  up  the 
vulva.  Whenever  practicable  he  prefers  in  this  unfortunate 
condition,  provided  the  urethra  is  unimpaired,  to  close  up  the 
vagina  as  high  up  as  possible,  so  that  the  marital  relations 
should  not  be  interfered  with.  In  uncomplicated  cases  of 
vesico-vaginal  fistula  he  prefers  the  use  of  shot  to  twisting  of 
the  wires,  because  they  form,  permanent  adjusters  and  prevent 
e version  of  the  edges  of  the  wound. 

VAGINITIS. 

Non-specific  and  acute  cases  of  vaginitis  Dr.  Goodell  treats 
by  such  hojt  and  emollient  injections  as  flaxseed,  or  slippery 
elm  bark  tea.  When  the  inflammation  has  subsided  vaginal 
suppositories,  containing  5  grains  of  iodoform,  are  ordered 
twice  or  thrice  daily.  In  the  chronic  forms  of  this  complaint 
he  uses  suppositories  of  tannin  or  iodoform,  or  long  tampons 
of  absorbent  cotton  dipped  in  astringent  solutions  of  acetate 
of  lead,  and  of  zinc  to  which  laudanum,  has  been  added. 

FUNGOUS   VEGETATIONS   OF   THE   ENDOMETRIUM. 

In  this  condition  Dr.  Goodell  removes  the  unhealthy  growth, 
either  by  the  dull  or  by  the  sharp  curette,  or  if  the  os  is  suffi- 
ciently patulous,  by  means  of  a  small  fenestrated  polypus  for- 
ceps. The  uterine  cavity  is  then  cleansed  with  a  saturated 
tincture  of  iodine  if  the  cervical  canal  is  not  very  open,  but 
when  it  is  gaping  he  prefers  Monsel's  solution.  In  the 
former  condition  he  avoids  the  use  of  the  iron,  because  it 
forms  clots  which  cannot  easily  be  expelled  from  the  womb 
without  causing  much  pain.  He  deems  the  iron,  however 
the  more  efficacious  treatment  of  the  two. 


The  Medical  and  Surg-icat  Diseases  of  Women.      109 
VAGINISMUS. 

Dr.  Goodell  had  never  yet  been  compelled  to  resort  to  the 
deep  posterior  incision  practiced  by  Dr.  Marion  Sims,  although 
in  two  cases  he  was  obliged  to  snip  off  irritable  carunculse 
my rti formes.  He  treats  this  disease  precisely  as  he  would 
treat  an  anal  fissure.  If  the  local  spasm  does  not  yield  to 
constitutional  treatment  and  to  vaginal  suppositories  of  mor- 
phia, belladonna,  carbolic  acid  and  iodoform,  he  puts  the 
woman  under  ether  and  forcibly  stretches  the  vulvo-vaginal 
opening  either  by  means  of  the  two  thumbs,  or  by  the  fore 
and  middle  fingers  of  each  hand. 


NERVOUS  DISEASES. 

IN    THE    PHILADELPHIA    HOSPITAL    FOB    DISEASES 
OF  THE   NERVOUS  SYSTEM. 

The  cases  found  in  these  wards,  which  are  in  charge  of  Dr. 
Charles  K.  Mills,  neurologist  to  the  hospital,  are  chiefly  ex- 
amples of  chronic  organic  disease  of  the  nervous  system — 
hemiplegics  from  hemorrhage,  thrombosis,  or  embolism ;  cere- 
bral, cerebro-spinal,  and  spinal  scleroses ;  meningitis,  meningo- 
encephalitis,  and  meningo-myelitis ;  epilepsy,  hystero-epilepsy, 
and  hysteria;  brain  tumors,  spinal  softening,  and  the  like. 
Acute  cerebral  and  spinal  disorders;  neuralgias,  peripheral 
paralyses,  local  spasmodic  diseases,  and  similar  affections,  are 
sometimes,  but  not  so  frequently,  represented. 

ELECTRICITY. 

In  connection  with  the  wards,  a  large  apartment,  known  as 
the  Electrical  Room,  has  been  fitted  up.  It  contains  one  of 
Flemming  &  Talbot's  permanent  batteries  of  sixty  cells,  and 
a  fine  faradic  instrument  from  the  same  manufacturers.  The 
wards  are  also  supplied  with  portable  galvanic  and  faradic 
instruments. 

Dr.  Mills,  during  the  past  year,  has  used  electricity  witk 
marked  success  in  the  treatment  of  bed-sores,  which,  in  spite  of 
the  best  of  care,  are  apt  to  form  in  cases  of  spinal  and  cerebral 
disease.  The  "silver-and-zinc-plate"  method  is  the  one  gen- 
erally employed,  a  silver  plate  being  placed  over  the  sore,  and 
a  zinc  plate  (connected  by  a  wire  with  the  silver)  on  a  piece  of 
acidulated  chamois  skin  or  paper  lint,  which  rests  on  the  un- 
broken skin  a  few  inches  above.  A  weak  current  from  the 
galvanic  battery  is  sometimes  used  instead  of  the  plates,  A 

110 


Nervous  Diseases.  Ill 

applied  to  the  sore  is  connected  with  the  negative 
electrode ;  an  ordinary  rheophore,  joined  to  the  positive  pole, 
being  placed  upon  the  surface  near.  The  seance  is  continued 
for  from  five  to  ten  minutes  daily.  Many  cases  of  chronic 
ulceration  put  into  the  hands  of  the  neurologist  for  electrical 
treatment  have  been  cured  by  the  galvanic  plates,  or  the  use 
of  the  battery  current.  Electricity  is  very  effectual  in  stimu- 
lating healthy  granulations. 

Faradization  is  used  in  the  wards  to  improve  the  condition 
of  palsied  muscles ;  and  central  galvanization  is  employed 
chiefly  in  spinal  affections. 

METALLOSCOPY  AND  METALLOTHERAPY. 

Numerous  experiments  in  metalloscopy  and  metal lotherapy 
have  been  made  in  the  Nervous  Wards,  only  a  few  of  which 
can  be  alluded  to  at  present. 

In  one  case  of  brain  tumor  with  partial  anaesthesia  of  the 
left  leg,  a  small  zinc  plate  applied  to  this  limb  in  an  hour  r 
caused  a  sensation  which  was  described  by  the  patient  as  being 
like  that  produced  by  the  "  battery,"  referring  to  a  faradic 
instrument.  Other  metals  were  tried,  but  had  no  effect. 
The  salts  of  zinc  were  used  without  success,  iodide  of  potas- 
sium being  the  only  remedy  that  seemed  to  help  the  case. 

Some  curious  results  were  obtained  in  a  number  of  cases  of 
marked  anaesthesia  from  hysteria  and  spinal  disease,  to  two  of 
which  reference  will  here  be  made. 

One  case  was  that  of  an  unmarried  woman,  aged  29,  sup- 
posed to  be  an  example  of  hysterical  paraplegia  and  anaesthe- 
sia. On  two  occasions  plates  of  zinc,  iron,  copper,  tin,  silver 
and  gold,  of  about  the  same  size  and  weight,  were  placed  on 
different  parts  of  the  body  simultaneously ;  at  other  times  the 
applications  were  varied — sometimes  one  plate,  sometimes  two 
or  three  were  used.  Many  trials  were  made,  the  patient  being 
blindfolded,  and  different  locations  being  selected  for  the  same 
plate.  In  five  instances  the  patient  picked  out  the  zinc  plate 


112  Notes  of  Hospital  Practice. 

in  from  twenty  to  forty  minutes,  saying  that  she  felt  under  it 
a  sensation  which  she  described  as  tingling,  or  as  like  "pina 
and  needles."  Twice  she  referred  similar,  but  weaker,  sen- 
sations to  the  plate  of  iron,  but  other  metals  gave  no  result. 

Sensation  was  temporarily  improved,  muscular  power  was 
apparently  increased;  and  the  anesthetic  limbs  bled  more 
freely,  on  pricking  them  with  needles,  after  the  zinc  was  ap- 
plied, until  the  peculiar  sensations  described  were  called  forth. 
This  patient  was  kept  upon  the  use  of  valerianate  of  zinc  for 
six  weeks — sensation,  motion,  and  her  mental  condition  -im- 
proving. Subsequently,  however,  she  relapsed. 

A  second  case  was  that  of  a  man,  aged  28 ;  an  advanced 
case  of  sclerosis  of  the  posterior  columns,  with  almost  absolute 
ansesthesia  of  the  lower  extremities.  After  carefully  testing 
the  condition  of  sensibility  and  of  the  circulation,  a  small  zinc 
plate  was  applied  to  the  right  calf,  and  a  silver  plate  of  the 
same  size  to  a  corresponding  part  of  the  left  leg.  In  thirty 
minutes  he  began  to  have  a  sensation  as  if  needles  were  prick- 
ing him  under  the  silver  plate.  Two  or  three  minutes  later 
he  had  a  similar^  but  weaker,  sensation  under  the  zinc  on  the 
right  limb.  The  plates  were  kept  on  ten  minutes,  during 
which  time  he  had  four  alternations  of  sensation  in  the  two 
sides.  When  the  pricking  sensation  was  present  under  the 
silver  plate  it  would  be  absent  under  the  zinc,  and  vice  versa; 
but  it  was  in  each  instance  much  more  decided  under  the 
silver.  On  removal  of  the  plates  electro-sensibility  was  de- 
cidedly improved.  No  change  of  sensibility  to  the  aesthesio- 
meter  or  state  of  the  circulation  was  produced.  The  symp- 
toms in  this  case  were  decidedly  ameliorated  by  both  nitrate 
and  oxide  of  silver,  but  were  not  permanently  benefited  by 
any  treatment. 

Dr.  Mills  does  not  believe  that  the  theory  of  "  expectant  at- 
rention  "  will  explain  satisfactorily  all  the  phenomena  which 
result  from  metallic  applications.  Patients  do  certainly  some- 
times exhibit  metallic  idiosyncrasies — whatever  may  be  the 
explanation.  Ansestlvesia,  even  when  the  result  of  organic 


Nervous  Diseases.  113 

disease,  can  be  temporarily  removed  by  applying  pieces  of 
metal.  He  has  observed  that  two  metals  will  sometimes 
produce  similar  effects  on  the  same  individual  •  but,  even  in 
these  cases,  he  has  always  found  that  one  of  the  two  will  give 
rise  to  more  decided  sensations,  and  will  be  more  positively 
effectual  in  removing  the  anaesthesia. 

In  regard  to  internal  metallotherapy,  it  is  somewhat  diffi- 
cult to  arrive  at  a  decision.  Irrespective  of  metalloscopic  in- 
vestigations, the  value,  in  chronic  spinal  diseases,  of  the 
preparations  of  zinc,  silver,  and  other  metals,  has  long  been 
known.  They  can  also  be  used  with  advantage  in  cases  in 
which  no  effect  is  produced  by  external  applications  of  metals. 
The  salts  of  silver  and  zinc  will  undoubtedly  bring  about 
amelioration  of  serious  symptoms  in  cases  in  which  these 
metals,  when  applied  to  anaesthetic  limbs,  will  be  selected  by 
patients  in  preference  to  others,  because  of  the  peculiar  sensa- 
tions which  they  cause. 

MASSAGE   AND   SWEDISH   MOVEMENTS. 

Both  massage  and  Swedish  movements  are  employed  to  a •- 
considerable  extent,  some  of  the  nurses  being  trained  for  this 
work.  Massage  is  found  to  be  of  benefit,  even  in  old  cases 
of  paralysis,  serving  to  keep  up  nutrition  and  temperature, 
and  preventing  trophic  changes.  In  neuralgic  and  hysterical 
cases  it  also  often  proves  of  great  service-. 

In  the  same  room  in  which  the  permanent  electrical  instru- 
ments are  kept,  are  some  simple  forms  of  apparatus  for  the 
movement  treatment,  such  as  a  crossbar  adjustable  at  various 
heights,  a  leaning  cylinder  for  exercising  the  muscles  of  the 
trunk,  a  stool  of  the  proper  height  and  size  for  sitting  move- 
ments, and  a  lounge  or  couch  so  hinged  as  to  be  capable  of 
being  inclined  at  various  angles.  The  patients  are  taught  to 
practice  movements  with  or  without  assistance,  according  to 
the  nature  of  the  case. 

A  movement  treatment,  without  apparatus,  is  also  often 


!  1 4  Notes  of  Hospital  Practice. 

used.  The  kinds  of  movements  usually  resorted  to,  without 
.appliances,  are  the  passive,  or  the  duplicated  active.  Syste- 
matic passive  movements  are  employed  for  the  purpose  of 
preventing,  as  far  as  possible,  atrophy  and  deformities.  Joints 
°.re  kept  in  a  healthier  condition  through  the  agency  both  of 
massage  and  these  passive  movements.  Duplicated  active 
movements  are  used  in  those  cases  in  which  the  loss  of  power 
in  sclerotic  or  paralytic  patients,  for  instance,  is  not  absolute. 
In  conjunction  with  faradization  this  method  of  treatment 
often  results  in  the  marked  improvement  of  the  paralyzed 
limbs,  palliating  symptoms,  and  improving  circulation  and 
nutrition  even  of  palsied  limbs. 

THE   ACTUAL   CAUTERY. 

The  actual  cautery,  either  alone  or  conjoined  with  other 
remedies,  is  frequently  resorted  to  in  the  treatment  of  epilepsy, 
and  of  chronic  spinal  diseases.  The  ordinary  cautery-iron, 
with  a  button  shaped  like  the  blunt  end  of  an  olive,  lias 
usually  been  employed,  but  recently  the  hospital  has  obtained 
a  Pacquelin  cautery,  in  which  the  vapor  of  pure  benzine  is 
forced  by  an  air-blast  upon  a  piece  of  hot  platinum.  Super- 
ficial applications  to  the  nape  of  the  neck,  or  along  the  spinal 
column,  are  made  every  two  or  three  days.  The  intervals 
between  epileptic  seizure  have  been  extended  from  days  to 
months  by  the  use  of  the  cautery 

THE   TREATMENT   OF   SYPHILITIC   BRAIN   DISEASE. 

The  wards  are  nearly  always  well  supplied  with  syphilitic 
affections  of  the  brain  and  cord.  Iodide  of  potassium  in 
energetic  doses  is  largely  employed.  Mercurial  inunction  has 
also  been  extensively  tested,  and  in  a  few  instances  with 
striking  results.  From  £  a  drachm  to  1 J  drachms  of  mercurial 
ointment  is  used  daily,  or  every  other  day,  the  treatment  being 
persisted  in  until  seme  effect  is  produced,  or  good  reasons 


Nervous  Diseases.  115 

arise  for  its  discontinuance.  Before  inunction,  the  parts  to 
which  the  ointment  is  to  be  applied  are  well  sponged  with 
warm  water.  Strict  attention  is  paid,  at  the  same  time,  to 
diet  and  hygiene. 

TREATMENT  OF  SPINAL,  SCLEROSES. 

For  the  various  forms  of  spinal  scleroses,  and  particularly 
for  posterior  spinal  scleroses,  or  looomotor  ataxia,  the  salts  of 
silver  —  the  nitrate,  phosphate,  or  oxide  —  are  generally  found 
to  be  the  most  efficacious  internal  remedies.  They  are  used 
in  doses  of  from  £  to  £  a  grain,  and  are  often  combined  with 
some  bitter  tonic,  as  the  extract  of  gentian  or  quassia.  Elec- 
tricity, in  the  form  of  moderately  strong  gal  vanic  currents,  is  also 
much  used  ;  stabile  xsurrents  to  the  spine,  and  labile  currents  to 
the  limbs  being  the  most  common  methods  of  application.  Early 
in  posterior  scleroses  large  doses  of  ergot  are  often  prescribed. 

THE  TREATMENT   OP  CEREBRAL  AND  SPINAL  EXHAUSTION. 

Preparations  of  phosphorus  are  used  in  the  treatment  of 
cases  which  show  signs  of  cerebral  or  spinal  exhaustion.  A 
favorite  preparation  of  this  substance  is  the  oil  of  phosphorus 
of  the  Prussian  Pharmacopeia.  This  oil  is  administered 
according  to  the  following  formula,  which  is  also  used  at  the 
Hospital  of  the  University  of  Pennsylvania  ; 


R     Olei  phosphorati 

Olei  ganltheriie 

Mucilag.  acacitt  ..........................................  q.  s.  ad  f^j.       M. 

Sio.  —  One  to  two  teaspoonfuls  three  times  daily. 

The  oil  of  phosphorus  itself  can  be  prepared  by  the  follow- 
ing process  :  u  Into  5  fluid  drachms  of  pure  almond  or  olive 
oil,  contained  in  a  glass  flask,  drop  3  grains  of  transparent 
phosphorus.  Place  the  whole  in  a  water-bath  at  175°  F., 
and  agitate  until  dissolved." 


116  Notes  of  Hospital  Practice. 

CALABAR  BEAN  IN  DEMENTIA  PABALYTICA 

Calabar  bean  is  prescribed  in  dementia  paralytica,  cases  of 
\vhich,  in  the  early  stages  of  the  disease,  sometimes  find  their 
way  into  the  Nervous  Wards.  If  not  promptly  relieved, 
they  are  transferred  to  the  Insane  Department.  Pills  of  the 
ext.  physostig.  venenas,  each  containing  l/'g  to  the  1/3  of  a 
grain,  are  given  three  times  daily,  the  treatment  being  per- 
sistently continued  and  the  effects  of  the  drug  constantly 
watched.  Rest,  nourishment,  and  counter-irritation  to  the 
head  or  nape  of  the  neck  are  conjoined  with  the  calabar  bean. 

GENERAL  NOTES. 

Cannabis  indica,  hyoscyamus,  conium,  morphia,  chloral, 
and  bromide  of  potassium  are  used  to  fulfil  various  indications, 
such  as  tremor,  headache,  sleeplessness,  mental  symptoms,  etc, 

APOPLEXY. 

In  the  treatment  of  the  apoplectic  state  the  patients  do  not 
stand  depletion  well.  Bleeding  is  seldom  employed.  Sup- 
porting measures  are  often  found  to  be  necessary  to  carry  the 
cases  successfully  through  the  attacks. 

THREE  INTERESTING  CASES  OP  SPINAL  DISEASE. 

CASE  I. — The  patient,  a  sailor,  was  brought  into  the  hos- 
pital with  a  history  of  a  fall  of  thirty  feet  from  the  rigging 
of  his  ship  while  at  sea.  He  fell  partly  on  his  head  and 
partly  on  his  back.  When  picked  up  he  was  unconscious, 
and  remained  so  for  fifteen  minutes.  Upon  regaining  con- 
sciousness he  found  that  his  right  arm  and  leg  were  entirely 
paralyzed,  and  the  left  arm  almost  entirely  so.  The  patient 
received  no  treatment  whatever  while  at  sea. 

Since  admission  the  patient  had  been  carefully  examined 


Nervous  Diseases.  117 

and  found  to  be  free  from  any  disease  of  his  heart,  lungs, 
liver,  or  kidneys.  The  ophthalmoscope  revealed  a  slight  optic 
neuritis,  but  not  enough  to  indicate  any  serious  disease  of  the 
brain.  When  he  walked  he  carried  his  head  somewhat  for- 
ward. The  effort  to  straighten  the  head  gave  the  patient 
pain.  At  the  point  of  junction  of  the  cervical  and  dorsal 
spine  some  thickening  and  induration  were  found.  The  right 
arm  had  not  entirely  recovered  its  power.  He  was  unable 
either  to  extend  or  close  the  fingers  of  that  hand.  There  was 
some  atrophy  of  the  muscles  of  that  hand.  The  circulation 
of  the  same  limb  was  also  found  to  be  very  defective.  The 
left  hand  and  arm  exhibited  the  same  conditions,  but  to  a 
lesser  degree  than  the  right  arm.  The  man's  walk  was  pecu- 
liar. The  right  leg  was  stiff  and  trembled  when  he  walked. 
Upon  stripping  the  limb  the  feet  were  found  to  be  abnormally 
extended.  Attempts  to  bring  the  foot  up  to  a  right  angle 
were  attended  with  great  trembling  of  the  member  and 
marked  tension  of  the  tendo  Achillis.  The  tendon  reflex  of 
the  patella  of  both  legs  was  most  marked.  There  was  no 
decided  impairment  of  the  sensation  of  either  touch  or  pain 
in  the  feet.  Contraction  of  the  muscles  under  the  faradic 
current  was  slightly  impaired  in  both  legs  and  arms.  Now 
and  then  trembling  could  be  produced  by  pressure  upon  the 
lower  part  of  the. spinal  column. 

In  debating  the  case,  two  difficulties  were  encountered. 
First,  in  connection  with  the  nature  of  the  original  injury; 
and  second,  as  regarded  the  present  nature  of  the  disease. 
Concerning  the  first  point,  concussion  of  the  spine  seemed 
hardly  possible,  since  it  could  not  account  for  the  paralysis  of 
the  muscles  of  three  extremities.  It  seemed  more  probably 
to  have  been  a  case  .of  apoplexy  of  the  cord.  It  was  con- 
cluded, however,  that  the  .effiision  of  blood  could  not  have 
been  a  large  one,  since  there  was  no  paralysis  of  the  left  leg, 
no  urinary  difficulty,  and  110  pronounced  tendency  to  the 
formation  of  bed-sores. 

Concerning  the  second  point  to  .be  decided,  it  was  though* 


1 18  Notes  of  Hospital  Practice. 

by  Dr.  James  H.  Hufcchinson  that  the  symptoms  then  present 
pointed  conclusively  to  an  involvement  of  the  lateral  columns. 
This  opinion  was  strengthened  by  the  presence  of  spastic  mus- 
cular contractions.  The  absence  of  anaesthesia  proved  that 
the  posterior  columns  could  not  be  seriously  aifected,  and  the 
absence  of  analgesia  seemed  to  show  the  same  to  be  true  of 
the  gray  matter.  It  was  thought  that  simple  concussion  of 
the  spine  was  sufficient  to  produce  inflammation  of  the  lateral 
columns. 

As  soon  as  the  patient  entered  the  wards  a  blister  was 
applied  to  the  seat  of  induration  in  the  back,  and  bromide  of 
potassium  administered  internally.  When  it  was  seen  that 
inflammation  of  the  cord  existed,  1/16  of  a  grain  of  bichloride 
of  mercury  was  ordered  four  times  a  day.  Later  he  was  put 
upon  gr.  x  of  potassium  iodide  thrice  daily,  which  dose  was 
subsequently  doubled.  It  was  remarked,  in  connection  with 
the  early  history  of  the  case,  that  ergot  and  belladonna  would 
have  been  the  proper  remedies  to  employ  immediately  upon 
the  reception  of  the  original  injury. 

For  the  future,  occasional  blisters  were  ordered  and  rest  was 
enjoined.  Strychnia  and  electricity  were  regarded  as  injurious. 

CASE  II. — A  farmer,  with  a  good  family  history,  who  had 
spent  a  day  in  very  hard  work,  and  during  the  following 
night  had  been  much  exposed  to  cold  and  wet.  This  impru- 
dence, which  took  place  eleven  months  before  his  admission 
to  the  hospital,  was  followed  by  loss  of  power  in  the  lower 
extremities  and  complete  paralysis  of  the  bladder. 

For  two  or  three  months  after  this  period  the  patient  had 
shooting  pains  in  his  legs,  and  was  much  troubled  with  noc- 
turnal delirium. 

The  man  was  carefully  examined  by  Dr.  DaCosta  after  his 
admission,  and  found  to  be  suffering  from  marked  paraplegia 
without  involvement  of  the  rectum  or  bladder.  The  strong 
faradic  current  elicited  no  response  whatever  in  either  leg, 
except  from  the  flexors  of  one  of  the  big  toes ;  using  the  con- 
tinued current  the  same  results  were  observed. 


Nervous  Diseases.  119 

The  case  was  regarded  as  a  typical  one  of  acute  spinal  par- 
alysis— a  rare  form  of  disease  in  the  adult — in  which  the 
lesion  was  in  the  anterior  horns  of  the  spinal  cord.  The  loca- 
tion of  the  lesion  was  thought  to  account  for  the  entire  loss  of 
electro-muscular  contractility,  while  sensation  was  so  little 
impaired.  It  was  also  thought  to  account  for  the  absence  of 
ectal  and  vesical  difficulties  and  of  bed-sores. 

CASE  III. — A  shoemaker,  who  stated  that  his  troubles 
dated  back  to  an  attack  of  rheumatism  in  his  legs.  This 
rheumatic  attack  lasted  about  three  weeks.  Pains  in  the  back 
and  legs  were  associated  with  rheumatism. 

When  admitted  to  the  hospital  the  man  complained  greatly 
of  pains  in  the  limbs  and  back,  and  of  loss  of  power  in  the 
lower  extremities.  He  still  walked  with  difficulty  and  pain, 
but  the  local  tenderness  and  discoloration  had  gone.  It  was 
difficult  to  decide  whether  the  pains  complained  of  were  due 
to  the  rheumatism  in  the  extremities.  It  was  concluded  that 
they  were  not.  The  man  improved  very  rapidly  tinder  the 
use  of  the  iodide  of  potassium  and  ergot,  and  was  discharged 
entirely  cured,  as  it  was  supposed.  Ten  days  afterward,  how- 
ever, he  was  again  admitted.  Upon  questioning  him  closely 
it  was  discovered  that  he  had  spent  all  the  time  since  his  dis- 
charge in  walking  about  the  city  in  search  of  employment. 

After  his  return  to  the  wards  he  began  to  lose  power  in  his 
legs  steadily.  The  pains  in  his  back  and  legs  returned,  and 
he  spoke  of  a  feeling  of  great  constriction  around  his  waist. 
Still  later  the  legs  began  to  atrophy,  and  still  the  loss  of  power 
remained.  The  electro-muscular  contractility  was  very  much 
diminished,  while  the  sensibility  seemed  to  be  slightly  deficient 
in  both  of  the  lower  limbs.  The  capillary  circulation  was 
very  defective,  the  blood  circulating  very  irregularly  in  the 
superficial  tissues.  Reflex  sensibility  still  remained  intact. 
The  muscular  sensibility  had  gradually  increased. 

It  was  concluded  very  early  in  the  progress  of  this  case 
that  it  was  one  of  rheumatic  paralysis  of  the  cord,  or  rheumatic 
spinal  myelitis. 


J20  Notes  of  Hospital  Practice. 

Anatomically  speaking,  it  was  pointed  out  that  the  lesions 
in  Cases  II  and  III  were  the  same,  both  being  located  in  the 
anterior  horns,  but  in  Case  II  there  was  no  rheumatism,  and 
the  spinal  paralysis  came  on  at  once;  while  in  Case  III  the 
rheumatic  origin  was  plain,  and  the  spinal  complications  came 
on  at  a  later  period.  The  treatment  of  Case  III  was  by  gr. 
xv  of  the  iodide  of  potassium  thrice  daily,  with  a  little  iron 
£nd  locally  friction. 

In  the  discussion  of  Cases  II  and  III  some  very  interest- 
ing points  were  brought  out.  Particular  attention  was  directed 
to  the  rapid  atrophy  of  the  muscles  of  the  lower  extremities  in 
both  of  the  cases.  This  atrophy  was  emphasized  as  being  the 
most  typical  and  constant  symptom  of  this  class  of  affections, 
the  rapidity  with  which  this  atrophy  progresses  being  in  pro- 
portion to  the  acuteness  and  persistency  of  the  attack. 

Another  fact,  to  which  particular  attention  was  directed, 
was  that  this  atrophy,  as  a  general  rule,  is  not  permanent. 
In  caiaes  where  recovery  has  been  more  or  less  complete,  the 
limbs  are  found  to  have  regained,  to  a  greater  or  less  degree, 
their  normal  shape  and  power,  the  completeness  of  the  return 
of  the  limb  to  its  normal  shape  being  dependent,  of  course, 
upon  the  completeness  of  the  patient's  convalescence.  Com- 
plete restoration  to  power  and  health  was  regarded  as  rare. 
It  was  argued  that  the  real  extent  of  the  damage  done  de- 
pended upon  the  number  of  trophic  cells  which  had  been 
destroyed.  If  enough  of  them  remained  intact,  when  the 
morbid  process  had  ceased,  to  minister  sufficiently  to  the  sup- 
ply and  nourishment  of  the  atrophied  muscles,  it  was  easy  to 
restore  their  for  a  time  lost  functions  by  means  of  proper 
nerve-food,  friction  and  electricity  in  the  shape  of  galvanism, 
and  in  the  later  stages  by  the  hypodermic  use  of  strychnia. 

The  question  arising  as  to  whether  the  tape-measure  was 
the  only  means  of  judging  definitely  of  the  condition  of  the 
affected  muscles,  it  was  pointed  out  that  when  it  was  found 
upon  trial  that  the  faradic  current  when  applied  to  the  affected 
muscles  began  to  give  better  results,  and  when  the  muscles 


Nervous  Diseases.  121 

began  to  respond  and  contract,  though  feebly,  it  might  be  ac- 
cepted as  a  sure  sign  of  returning  health,  for  it  proved  con- 
clusively that  the  muscles  were  becoming  more  active,  and 
that  the  paralysis  had  reached  its  height. 

It  was  thought  that  the  same  conclusion  could  not  be  drawn 
from  the  use  of  the  continuous  current,  the  muscles  respond- 
ing to  this  current  so  soon  that  it  could  not  be  regarded  as 
any  gauge  at  all. 

Attention  was  called  to  the  facts  of  the  entire  absence  of 
rectal  and  vesical  paralysis,  and  of  bed-sores,  in  Cases  II  and 
III. 

In  one  point  it  was  shown  that  these  two  cases  had  not  been 
typical  ones  of  their  kind,  viz.,  in  so  far  as  the  reflex  nerv- 
ous functions  had  not  been  in  the  least  impaired  in  either  case. 

The  treatment  was  limned  out  by  Dr.  DaCosta,  as  having 
consisted  at  first  of  local  blood-letting  in  the  neighborhood  of 
the  spine,  occasional  purging,  and  large  and  continuous  doses 
of  ergot.  This  at  first;  later  the  indications  were  met  by 
large  doses  of  the  iodide  of  potassium,  and  by  the  application 
of  systematic  friction  to  the  legs.  Later  still,  it  was  thought 
that  small  doses  of  strychnia  should  be  administered  hypo- 
dermically,  and  when  muscular  motion  returned,  that  the 
farad ic  current  should  be  employed. 

CHOREA. 

Dr.  Wharton  Sinkler  has  controlled  the  twitchings  of 
patients  with  this  disease  by  the  continued  hypodermic  injec- 
tion of  from  3  to  5  drops  of  Fowler's  solution.  In  some 
of  the  instances,  the  injections  were  followed  by  a  good  deal 
of  local  irritation. 

Dr.  H.  C.  Wood  has  treated  successfully  several  cases  of 
this  disease,  with  a  saturated  tincture  of  the  rhizome  of  dra- 
contium.  The  dose  at  first  is  60  drops  thrice  daily,  and  it  is 
gradually  increased  to  90  drops.  Particular  care  is  taken  that 
the  preparation  of  the  drug  used  is  a  reliable  one. 


122  Notes  of  Hospital  Practice. 

PARALYSES   OF  THE   RECURRENT   LARYNGEAL   NERVE. 

Nerve  tonics,  such  as  strychnia,  phosphorus,  iron,  and  cod- 
liver  oil,  are  used.  In  the  so-called  instances  of  hysterical 
and  nervous  aphonia,  a  sponge-probang  is  moistened  and 
brought  into  contact  with  the  vocal  cords,  which  are  thus 
thrown  into  a  state  of  spasm  and  so  brought  together.  The 
same  effect  is  produced  in  other  cases  by  sprays  of  ether 
projected  upon  the  part,  or  by  inhalations  of  pungent  sub- 
stances. 

"When  all  else  fails,  electricity  is  employed  and  is  applied 
directly  to  the  paralyzed  muscle. 

In  using  electricity,  the  plan  pursued  by  Dr.  Cohen  is  to 
place  one  electrode  directly  over  the  crico-thyroid  ligaments 
outside,  and  then  to  carry  the  other  electrode  into  the  larynx 
and  place  its  point  in  contact  with  the  cords,  or  between  them. 
The  electrode  in  the  throat  is  only  kept  in  position  a  few 
seconds  at  a  time.  Cures  are  often  effected  in  this  way  by  a 
single  application. 

Where  intra-laryngeal  electric  excitation  is  not  possible,  the 
percutaneous  method  is  tried.  This  consists  in  passing  a  cur- 
rent from  one  side  of  the  neck  to  the  other,  and  so  through 
the  larynx.  Or,  the  patient  is  placed  upon  the  insulating 
stool  and  a  spark  is  drawn  from  the  cricoid  cartilage  with  the 
knuckle. 

In  cases  of  hysterical  aphonia  a  cure  is  often  effected 
by  the  mere  introduction  of  the  laryngeal  mirror,  the 
patient  being  given  to  understand  that  this  is  the  curative 
procedure. 

Another  method  often  tried  is  to  stand  behind  the  patient 
and  grasp  the  thyroid  cartilage  between  the  thumb  and  fore- 
finger, while  at  the  same  time  the  middle  finger  is  placed 
under  the  cricoid  cartilage,  pulling  it  up  and  in  front  of  the 
thyroid.  In  this  way  the  vocal  cords  are  stretched  and  made 
tense,  and  so  caused  to  vibrate  by  means  of  the  inspiratory 
current. 


Ne/vous  Diseases.  123 

TETANUS. 

Systematic  feeding  of  patients  with  liquid  and  strengthen- 
ing food  at  short  intervals,  has  been  employed  by  Dr.  H.  0. 
Wood  with  very  good  results.  The  food  is  given  at  intervals 
of  every  two  or  three  hours,  and  consists  mainly  of  milk, 
with  a  small  quantity  of  alcohol.  In  severe  cases  all  solid 
food  is  avoided.  As  regards  medicines,  the  patient  is  brought 
well  under  the  influence  of  the  bromide  of  potassium  by  an 
initial  dose  of  from  2  drachms  to  J  an  ounce,  to  be  followed 
by  ^  a  drachm  to  a  drachm  every  three  or  four  hours.  To 
force  sleep  at  night,  30  grains  of  chloral  are  given  at  bed-time 
with  some  opium.  Chloral  is  also  used,  when  necessary,  in 
the  day-time.  Nitrite  of  amyl  and  chloroform  are  never  used 
steadily,  but  are  employed  from  time  to  time  to  stop  violent 
spasms.  Where  there  is  much  cerebral  congestion,  a  blister 
is  applied  to  the  nape  of  the  neck. 

WEAVER'S,  VIOLINISTS,  AND  IRON  PULLER'S  PALSIES. 

CASE  I. — W.  B.  C.,  by  profession  a  violinist,  has  been  a 
steady  player  for  twenty  years,  averaging  six  hours  out  of 
every  twenty-four.  Patient  presented  himself  for  treatment 
January  27th,  1875,  saying  that  one  year  before  that  date  he 
first  noticed  a  spasm  of  the  flexors  of  the  ring  and  little  fingers 
during  an  attempt  to  lift  them  from  the  cords  of  the  violin. 
When  playing  he  had  pain  in  the  ulnar  region  of  the  arm. 
Used  to  play  first  violin ;  but  for  a  year  had  been  obliged  to 
play  second  violin. 

Sensation  and  electro-muscular  contractility  remained  unim- 
paired. 

He  holds  neck  of  violin  between  the  thumb  and  forefinger, 
touching  the  cords  with  the  other  fingers.  He  occasionally 
experiences  a  momentary  cramp  in  the  fourth  and  fifth  fingers 
in  lifting  them  off  the  cords.  Was  able  to  play  the  piano  with- 
out any  difficulty. 


124  Notes  of  Hospital  Practice. 

September  2,7th,  1875. — Trouble  still  continued  in  the  third 
finger  of  the  left  hand,  which  hung  on  his  violin  string  when 
it  should  be  raised  off  it.  Doubtful  of  any  improvement 
Advised  galvanization  of  flexors  and  extensors,  one  pole  in 
axilla,  the  other  stroked  over  the  muscles. 

CASE  II. — W.  V.,  set.  35  years,  a  heater  in  a  rolling  mill, 
who  worked  in  an  iron  foundry  at  Catasauqua,  pulling  the 
iron  in  and  out  of  the  furnace. 

Patient  had  been  married  and  had  four  healthy  children. 
He  denied  syphilis,  and  had  always  enjoyed  good  health  up 
to  the  date  of  his  present  troubles.  He  came  for  treatment  on 
March  25th,  1872,  with  the  statement  that  after  working  three 
successive  terms  at  the  furnace,  and  sleeping  from  seven  to 
nine  A.  M.,  he  went  to  a  pic-nic.  The  next  day  when  he 
woke  up  he  found  his  hands  swollen  and  stiff.  This  was  on 
a  Friday.  He  did  not  resume  work  until  Monday,  by  which 
time  the  swelling  of  the  hands  was  less  marked.  He  worked 
steadily  for  a  month,  the  strength  in  his  hands  failing,  the 
grip  becoming  weak,  with  a  feeling  of  numbness  but  no  loss 
of  sensation. 

During  this  time  his  wife  died,  and  he  was  much  distressed. 
For  a  month  after  her  death  he  worked,  and  at  the  end  of  that 
time  was  obliged  to  stop.  Since  then  the  strength  in  his 
hands  has  steadily  failed,  commencing  in  the  hands  and 
extending  up  the  arms. 

There  was  some  pain  in  the  small  of  the  back,  some  diffi- 
culty in  articulating,  and  also  in  "  hawking."  No  dyspeptic 
symptoms.  Bowels  very  irregular.  Passed  urine  but  once 
during  the  day,  and  it  never  drippled  away.  No  blue  lines 
on  the  gums. 

There  was  absolute  loss  of  power  in  the  deltoids,  though 
the  fibres  of  the  muscles  contracted.  No  power  in  biceps, 
and  the  greatest  palsy  in  the  flexors  of  the  fingers  and  hands. 
Able  to  raise  wrist,  and  to  pronate  and  supinate  arms.  Loss 
of  power  in  the  triceps  muscles  not  so  marked  as  in  the  others, 
the  right  triceps  being  stronger  than  any  other  arm  muscles. 


Nervous  Diseases.  12o 

Pectoral  muscles  weak.  All  the  muscles  were  about  equally 
atrophied,  and  to  a  considerable  extent. 

Sensibility  and  localization  good.  Could  test  the  distance 
of  points  well. 

Some  loss  of  power  in  uvula  apparent.  Both  right  and  left 
arm  measured  7J  in.  at  a  point  three  inches  below  the  elbow. 

Electric  condition. — The  secondary  induced  current  one  cell, 
three  inches,  moved  both  deltoids,  most  marked  contraction 
being  obtained  by  placing  the  positive  pole  over  the  brachial 
plexus,  and  the  negative  over  the  muscle.  Electro-muscular 
contractility  remained  in  all  the  muscles,  but  was  diminished 
in  degree  except  in  the  flexor  coinmuuis  digitorum.  Electro- 
muscular  sensibility  existed  in  both  arms. 

3 .  ext.  ergot,  fl.,  gtt.  xx.,  and  potass.  i<>did.,  gr.  v.,  t.  d. ;  also 
advised  the  use  of  galvanism. 

April  2d. — The  dose  of  the  medicine  was  diminished  one- 
half  in  consequence  of  its  purging  him.  One  week  later  it 
was  found  necessary  to  discontinue  it  entirely  for  the  samf 
reason. 

April  30th. — After  eighteen  applications  of  galvanism  there 
was  no  improvement,  and,  returning  home,  he  died  about  the 
middle  of  May. 

CASE  III. — J.  B.,  set.  26  years,  a  weaver  by  occupation. 
His  family  history  has  been  good;  so  also  has  his  previous 
health  l>een.  Patient  has  been  a  weaver  since  he  was  fourteen 
years  of  age,  using  his  left  hand  as  much  as  the  right  in 
weaving.  When  fifteen  years  old  he  began  to  be  troubled 
with  spasmodic  pronation  of  the  left  hand.  He  stopped  work 
for  a  few  weeks,  and  upon  returning  was  not  troubled  with 
it  again  until  he  was  twenty-one  years  of  age,  when  it 
re-appeared,  and  has  continued  permanent  ever  since,  except 
when  he  could  stop  weaving  temporarily. 

The  spasm  consists  of  a  sudden  pronation  of  the  left  hand, 
with  a  general  tremor  of  the  arm,  caused  by  any  voluntary 
exertion — a  large,  irregular  tremor.  Any  movement  of  the 
hand  with  the  arm  flexed  is  more  difficult  to  perform  than 


1 26  Notes  of  Hospital  Practice. 

with  the  arm  extended.  Patient  is  unable  to  comb  his  hau 
backwards  with  the  left  arm. 

He  was  naturally  left-handed,  and  when  he  first  presented 
himself  for  treatment  at  the  clinic,  the  dynamometer  registered 
with  the  left  hand  135,  right  150. 

Sensation  was  unimpaired  in  both  hands.  There  was  no 
pain  in  the  back  of  the  neck  ;  but  a  "  bruised  "  feeling  in  left 
arm  after  exertion.  Advised  change  of  occupation  and  gal- 
vanism three  times  weekly  to  arm. — Dr.  S.  Weir  Mitchell. 

FACIAL     PARALYSIS,     FOLLOWED     BY     SECONDARY    SPASMS 
AND   CONTRACTURES. 

R.  S.,  set.  46,  a  married  woman,  came  under  observation 
late  in  the  winter.  Three  weeks  before,  without  known 
cause,  except  that  she  was  at  times  considerably  exposed  to 
the  changes  of  weather,  she  suddenly  became  paralyzed  on 
the  left  side  of  the  face.  Her  menses  had  been  irregular  foi 
six  months,  and  she  had  not  been  feeling  very  strong  for  a 
year. 

Examination  showed  complete  paralysis  of  the  muscles  sup- 
plied by  the  external  third  of  the  facial  nerve.  The  left  side 
of  the  face  was  smooth.  She  could  not  wrinkle  the  left  half 
of  the  forehead,  nor  close  the  left  eye.  The  nose  was  drawn 
very  slightly  to  the  right,  and  the  mouth  in  the  same  direc- 
tion and  upwards.  She  could  not  pucker  the  mouth.  Her 
speech  was  somewhat  indistinct,  and,  when  eating,  food  often 
lodged  between  the  left  cheek  and  the  teeth,  causing  annoy- 
ance. The  conjunctiva  of  the  left  eye  was  usually  injected, 
and  she  complained  frequently  of  pain  and  discomfort  in  this 
eye. 

The  velum  palati  and  uvula  were  unaffected.  She  had  no 
loss  or  disturbance  of  taste  on  either  side  of  the  tongue. 
Smell  was  slightly  impaired.  Hearing  in  the  paralyzed  side 
was  normal,  being  neither  abnormally  acute,  nor  dull  nor  lost, 
and  she  had  no  noises  in  the  ear. 


Nervous  Disease*.  127 

The  muscles  responded  promptly  to  both  the  faradic  and 
galvanic  currents,  and  the  response  to  faradism,  which  was 
used  in  the  treatment,  continued  good. 

Iodide  of  potassium  was  prescribed  in  doses  of  10  grains 
three  times  daily ;  and  faradization  with  a  current  just  suffi- 
cient to  produce  muscular  contraction  was  employed  every 
other  day.  Positive  and  progressive  improvement  took  place, 
the  patient  gradually  recovering  power  in  all  of  the  affected 
muscles.  After  six  weeks  of  treatment,  however,  a  slight 
twitching  of  the  left  angle  of  the  mouth  began  to  be  noticed. 
In  a  few  days,  this  angle  of  the  mouth  was  drawn  up  almost 
constantly.  The  cheeks  and  lips  began  to  be  pressed  against 
the  teeth,  and  she  complained  of  a  band-like  feeling  around 
the  paralyzed  side  of  the  month.  She  had,  in  short,  an  irreg- 
ularly distributed,  but  marked  condition  of  spasm  in  most  of 
the  muscles  recovering  from  the  paralysis.  Now  and  then  a 
succession  of  rapid  twitches  would  be  noticed  in  the  muscles 
about  the  angle  of  the  mouth.  Less  frequently  similar 
twitchings  were  observed  in  the  orbicularis  palpebrarum 
muscles,  especially  in  its  lower  fibres.  Any  effort,  under  the 
influence  of  the  will,  to  use  certain  muscles  or  groups  of  mus- 
cles of  the  left  side,  would  cause  a  curious  appearance  of  dis- 
tortion and  grimacing,  owing  to  the  irregular  spasmodic 
actions  that  would  ensue.  When  the  mouth  .was  pulled  up- 
wards and  outwards,  for  instance,  the  eyelids  would  be  pressed 
together  and  the  digastric  muscle  would  be  called  into  play. 
The  patient  was  constantly  annoyed  by  an  unpleasant  feeling 
of  "drawing."  After  this  condition  had  lasted  from  one  to 
two  weeks  the  left  half  of  the  orbicularis  oris  and  the  zygo- 
matic  muscles  began  to  feel  hard  and  hypertrophied. 

On  the  appearance  of  the  spasmodic  symptoms,  the  use  of 
the  faradic  current  was  transferred  to  the  healthy  or  non-par- 
alyzed side  and  a  weak  galvanic  current,  uninterrupted,  was 
applied  to  the  zygomatic,  orbicular  and  other  muscles,  which 
were  the  seat  of  the  tonic  spasm  or  contractures.  Bromide  of 
potassium  and  valeriauate  of  zino  were  administered  inter- 


128  Notes  of  Hospital  Practice. 

nally,  and  belladonna  ointment  was  frequently  rubbed  into 
the  face.  Under  this  treatment  the  patient  improved,  and 
she  was  discharged  much  relieved,  but  not  entirely  cured,  as 
some  contracture  still  remained. 

The  secondary  contractures  and  spasms  observed  in  this 
case  have  been  noted  by  Dr.  Mills  as  occurring  in  varying 
degree  in  a  number  of  cases  of  facial  paralysis.  They  have 
been  studied  by  Duchenne,  Remak,  Hitzig,  Erb,  and  others. 
No  very  satisfactory  explanation  of  their  occurrence  has  been 
offered.  Hitzig  refers  the  symptoms  to  an  abnormal  excita- 
bility of  the  medulla  oblongata,  which  becomes  developed  in 
a  still  unknown  manner,  in  consequence  of  peripheral  facial 
paralysis.  (Erb  in  Ziemssen's  Cyclopaedia,  vol.  XI,  p.  109.) 
Dr.  Mills  believes  with  Erb,  that  the  condition  is  not  one  of 
"  electrical  muscle  tetanus,"  induced  by  electric  treatment,  as 
it  occurs  in  cases  in  which  no  electric  treatment  has  been 
employed.  Transient  states  of  spasms  in  cases  of  this  kind 
are  by  no  means  uncommon.  Assuming  the  doctrine  of  the 
localization  of  motor  centres  in  the  cerebral  convolutions  to 
be  true,  it  may  be  that  the  special  cervical  centres  for  various 
facial  movements,  temporarily  quiescent  during  the  existence 
of  the  paralysis,  as  recovery  takes  place  begin  to  act  in  an 
irregular  and  abnormal  manner. 

Whatever  may  be  the  true  theory  of  the  production  of  these 
secondary  spasms  and  contractures,  experience  has  proved  that 
they  are  best  treated  by  the  conjoint  use  of  internal  and  exter- 
nal measures.  The  bromides  and  preparations  of  zinc,  cimi- 
cifuga,  hyoscyamus,  arsenic  and  similar  articles,  should  be 
given  with  a  view  of  quieting  and  controlling  the  nervous 
centres,  while  at  the  same  time,  the  patient's  strength  is  sus- 
tained by  mild  tonics  and  abundant  nourishment.  A  weak, 
stable  galvanic  current  should  be  used  for  its  antispastic  effect 
directly  to  the  nerves  and  muscles.  Mild  faradization  of  the 
antagonistic  muscles  of  the  healthy  side  can  also  be  resorted 
to,  but  it  should  be  used  with  caution  and  not  too  often. 
Detmold's  mechanical  treatment  of  facial  paralysis  can  be 


Nervous  Diseases.  129 

applied  with  advantage  to  the  unaffected  side  with  the  view 
of  preventing  and  controlling  contractures  upon  the  opposite 
side.  This  is  carried  out  by  taking  a  piece  of  tin  wire,  or 
some  similar  material,  and  bending  it  at  both  extremities,  so 
that  one  end  can  be  passed  over  the  ear  and  the  other  hooked 
into  the  angle  of  the  mouth,  thus  affording  a  support  and  pre- 
venting the  drawing  to  the  other  side.  Hypodermic  injections 
of  sulphate  of  atropia,  gr.  l/10o  to  I/GO*  usi»g  n*116  needles, 
can  be  thrown  into  the  spastic  muscles;  and  here,  as  in  so 
many  other  cases  of  spasm,  superficial  applications  of  the 
white-hot  iron  to  the  back  of  the  neck,  or  over  the  muscles, 
may  prove  of  signal  service.  Cases  of  this  kind  sometimes 
obstinately  resist  all  therapeutic  measures. 

FACIAL    PARALYSIS,    WITH     LOSS    OF    HEARING,    TINNITUS, 
AND   PECULIAR   VERTIGO. 

B.  G.,  set.  52,  a  widow,  had  been  healthy  until  twelve  years 
before  admission,  when  she  had  a  severe  attack  of  rheumatism, 
chiefly  involving  the  knee  joints.  Four  weeks  later  she  be- 
gan to  have  violent  pain  in  the  right  side  of  her  head,  which 
subsequently  extended  to  the  top,  and  then  to  the  left  side. 
She  suffered  from  these  head  pains,  with  but  slight  intermis- 
sions, for  two  years,  when  total  paralysis  of  the  left  side  of 
the  face  made  its  appearance,  and  was  accompanied  by  loss  of 
hearing  and  by  noises  in  the  ears.  Spells  of  giddiness  of  a 
peculiar  character  came  on  with  the  paralysis.  On  attempting 
to  walk  she  would  soon  be  compelled  to  run,  and  on  getting 
into  a  run,  she  would  fall  on  her  face,  unless  she  could  stop 
herself  by  taking  hold  of  some  object.  She  felt  as  though 
she,  herself,  and  the  floor  under  her  were  going  around. 
These  vertiginous  spells  gradually  grew  less  frequent  and 
severe  as  the  patient's  general  health  became  better.  She  ha3 
never  had  a  discharge  from  the  ear,  but  has  suffered  from 
more  or  less  headache  ever  since  the  facial  palsy  occurred. 
For  three  months  she  had  double  vision.  For  six  months 


130  Notes  of  Hospital  Practice. 

she  had  some  difficulty  in  swallowing,  fluids  sometimes  being 
regurgitated  through  her  nose.  On  admission  the  right  side 
of  her  face  and  both  arms  and  legs  were  found  to  be  unaffected 
by  paralysis,  but  the  left  side  of  the  face  showed  marked 
paralysis  and  atrophy.  The  usual  lines  and  furrows  were 
obliterated,  and  the  cheek  sagged  downwards.  No  movements 
could  be  performed  by  any  of  the  muscles  supplied  by  the 
left  facial  nerve.  Lagophthalmos  was  marked,  the  left  eye- 
lids remaining  wide  open.  The  lower  lid  was  slightly  ectropic. 
The  conjunctiva  was  generally  somewhat  injected.  She  had 
full  control  of  the  movements  of  the  left  eye,  which  she  could 
move  in  any  direction.  A  peculiar  motility  of  this  eye  was 
noticeable.  It  was  almost  constantly  jerking  or  wabbling 
upwards  and  downwards,  going  slightly  outwards  in  its  ascent. 
Sight  in  this  eye,  when  it  was  fixed,  was  good.  Her  nose  and 
mouth  were  drawn  far  to  the  right.  She  had  no  control  what- 
eve  over  the  paralyzed  muscles;  she  could  not  dilate  the 
nostril,  raise  the  lip,  draw  upwards  or  outwards  the  angle  of 
the  mouth,  etc.  She  could  speak  distinctly  and  protrude  the 
tongue  without  visible  deflection.  The  uvula  pointed  slightly 
towards  the  right,  and  the  velum  hung  lower  on  the  left  than 
the  right  side.  On  touching  it  with  a  probe  it  retracted  up- 
wards and  towards  the  right.  Taste  was  generally  defective, 
but  it  could  not  be  made  out  distinctly  to  be  abolished  on  the 
anterior  part  of  the  left  half  of  the  tongue.  She  complained 
of  dry  ness  of  the  mouth.  Hearing  in  the  left  ear  was  entirely 
gone,  and  she  had  constant  noises  in  this  ear.  Smell  was 
defective,  but  no  differences  could  be  made  out  between  the 
paralyzed  and  healthy  side.  Sensation,  as  determined  by  the 
sesthesiometer  and  the  faradic  battery,  was  slightly,  but  un- 
doubtedly, diminished  on  the  affected  side.  Both  farado-con- 
tractility  and  galvano-contractility  were  also  much  diminished. 
Reflex  movements  could  not  be  produced  by  irritating  the 
skin  of  the  face.  The  surface  temperature  was  carefully  taken 
in  the  middle  of  each  cheek;  it  was  91.8°  F.  on  the  left  or 
paralyzed  side,  and  95.t "  F.  on  the  right.  At  times  ene  still 


Nervous  Diseases.  131 

had  spells  of  giddiness.  On  going  up  stairs  she  became 
giddy,  but  was  never  troubled  in  this  way  on  coming  down. 
Her  appetite  was  poor;  her  bowels  were  constipated;  she  was 
frequently  troubled  with  nausea,  particularly  in  the  mornings. 
The  nausea  was  not  accompanied  by  vertigo.  She  was  nerv- 
ous and  irritable,  and  her  general  condition  as  regards  strength 
was  not  good. 

The  symptoms  presented  by  this  case  were  interesting,  and 
some  of  them  unusual.  They  indicated  an  extensive  lesion, 
probably  a  rheumatic  or  syphilitic  exudation  or  tumor  com- 
pressing the  facial  nerve  at  the  base  of  the  skull.  Destruc- 
tive disease  of  the  petrous  portion  of  the  temporal  bone  might 
also  explain  the  case.  The  peculiar  form  of  vertigo  is  worthy 
of  note.  The  facial  nerve,  in  the  first  part  of  its  course, 
passes  forward,  resting  on  the  oerebellar  crus,  and  it  might  be 
considered  whether  an  involvement  by  the  disease  of  this  arm 
of  the  cerebellum,  or  of  the  cerebellum  itself,  had  not  some 
agency  in  the  production  of  the  vertigo,  and  the  tendency  tc 
run  and  plunge  forward.  Auditory  vertigo  does  not  usually 
take  the  form  presented  in  this  patient. 

Tlie  head  symptoms — -pain  and  vertigo — were  greatly  bene- 
fited by  the  use  of  iodide  of  potassium  and  quinine.  Strych- 
nia and  carbonate  of  iron  were  also  administered  with  the 
effect  of  improving  the  general  condition  of  the  patient. 
Massage  and  faradization  and  galvanization,  both  with  the 
continuous  and  the  interrupted  current,  were  persistently  em- 
ployed directly  to  the  nerve-branches  and  muscles,  but  with 
little  benefit,  as  both  nerve  and  muscle  degeneration  had  gone 
so  far  as  to  preclude  much  hope. — Di\  C.  K.  Mills. 

SPASM   OP   THE  SPINAL   ACCESSORY   NERVE. 

Dr.  Wood's  treatment  is  by  means  of  hot  irons  applied  to  the 
nape  of  the  neck  and  immediately  over  the  contracted  muscles. 
The  heat  used  is  intense,  and  is  only  very  lightly  applied,  so 
as  not  to  produce  a  very  deep  eschar.  Together  with  this 
cauterization  the  iodide  of  pote^'nm  is  administered. 


132  Notes  of  Hospital  Practice. 

SEXUAL  EXHAUSTION. 

When  this  condition  is  a  result  of  masturbation,  as  a  first 
and  most  important  step  the  patient  is  persuaded  to  stop  the 
practice  at  once  and  forever.  Then  the  hygienic  treatment  is 
in  order.  Enough  exercise  is  taken  each  day  to  produce  deci- 
ded fatigue.  Meat  is  forbidden  as  a  general  article  of  diet, 
and  the  patient  lives  largely  upon  farinaceous  food.  A  gen- 
eral meat  diet  has  been  proved  to  throw  a  great  strain  on  the 
kidneys. 

All  kinds  of  exercise  which  irritate  the  genital  organs  are 
strictly  forbidden  by  Dr.  H.  C.  Wood.  As  sleeping  on  the 
back  provokes  emissions,  the  patient  is  advised  to  always  sleep 
on  his  side  on  a  hard  bed,  with  as  few  covers  as  the  weather 
will  allow.  All  sexual  literature  and  theatrical  scenes  are 
avoided. 

As  regards  medical  treatment,  bromide  of  potassium  ia 
given  in  doses  of  from  20  grains  to  half  a  drachm  thrice 
daily,  or  in  the  place  of  the  bromide  5  grains  of  brominated 
camphor  are  given  three  times  a  day  in  emulsion.  Along 
with  this  soothing  treatment  iron  and  some  bitter  tonic  are 
with  propriety  employed.  In  some  instances  ergot,  by  reliev- 
ing the  congestion  of  the  spinal  centres,  does  great  good. 

The  treatment  of  sexual  exhaustion  from  excessive  venery 
is  about  the  same  as  that  just  sketched  out.  A  specific  remedy 
is  phosphorus.  Ergot  is  also  always  used,  where  there  is 
numbness  or  prickling  of  the  limbs. 

In  impotence,  with  spermatorrhoea,  the  following  prescrip- 
tion has  been  found  to  act  like  a  charm : 

R     Tine,  canthar gtt.  yj. 

Tine,  ferri  chlor gtt.  xv-xx.     M. 

SiO. — Thrice  daily  in  water. 

PARAPLEGIA   DUE  TO   A  SPINAL  SPRAIN. 

The  most  important  indication  is  thought  by  Dr.  Levis  to 
consist  in  producing  a  powerful  counter-irritant  effect  along 


Nervous  Diseases.  133 

the  spine,  with  a  view  of  removing,  if  possible,  the  plastic 
effusion  upon  which  the  paraplegia  depends.  With  this  indi- 
cation in  view,  the  most  powerful  counter-irritant  known, 
which  is  the  iron  at  a  white  heat,  is  employed.  In  using  the 
hot  iron  upon  a  patient,  he  is  placed  under  the  influence  of  an 
anaesthetic  and  six  issues  are  made,  three  upon  either  side  of 
the  spine,  in  the  lumbo-dorsal  region. 

There  is  a  nice  little  point  about  the  after-treatment  of  the 
cauterized  spots,  which  has  not,  as  a  rule,  received  the  atten- 
tion it  merits.  If,  after  the  hot  iron  has  been  applied,  the 
parts  be  left  exposed  to  the  air,  or  even  the  ordinary  cold 
water  dressing  be  applied,  the  patient  will  suffer  a  great  deal 
of  pain.  But  if  pure  carbolic  acid — which  has  simply  been 
deliquesced  by  the  application  of  a  moderate  heat,  so  that  it 
may  be  conveniently  spread  with  a  camel's-hair  pencil — be 
applied  to  the  cauterized  spots,  it  produces  such  a  marked 
anaesthetic  effect  as  to  take  away  almost  all  the  pain  which 
would  otherwise  harass  and  distress  the  patient.  This  is  a 
little  point,  but  one  which,  if  observed,  relieves  considerable 
suffering.  The  parts  are  protected  by  the  ordinary  patent  lint 
and  carbolized  oil  dressing,  which  is  covered  with  waxed 
paper,  and  secured  in  place  by  adhesive  strips. 

During  the  period  of  inflammation,  in  spinal  lesions  of  this 
character,  the  bromide  of  potassium  is  indicated ;  but  later  on 
in  the  affection,  strychnia  is  the  agent  upon  which  most  reli- 
ance is  placed. 


MISCELLANEOUS. 

THE    INTRAVENOUS    INJECTION    OP    MILK    IN    FUNCTIONAL 
AND  ORGANIC  ANEMIAS. 

A  female,  set.  33,  was  admitted  to  the  University  Hospital 
in  the  spring  of  1878,  suffering  from  extreme  anaemia  and 
spinal  irritability,  which  had  been  induced  by  a  series  of 
depressing  causes,  miscarriages,  hemorrhages,  mental  strains 
and  nervous  shocks,  the  latter  requiring  a  large  amount  of 
morphia  in  their  management.  Other  forms  of  treatment 
having  been  assiduously  persevered  in  without  any  good  effect, 
it  was  determined  to  inject  milk  into  her  veins.  On  June 
20th,  Dr.  Charles  T.  Hunter  opened  her  right  median  basilic 
vein  and  injected  five  fluid  ounces  of  fresh  cow's  milk,  the 
cow  being  milked  in  an  apartment  adjacent  to  that  in  which 
the  patient  lay.  The  immediate  results  of  the  operation  were 
most  striking.  Almost  as  soon  as  the  milk  entered  her  veins 
the  patient's  face  assumed  a  deep  purplish  color,  her  conjunc- 
tive became  injected,  and  she  clutched  at  her  throat.  These 
symptoms  disappeared,  however,  upon  lowering  the  funnel 
and  allowing  the  milk  to  flow  in  more  slowly.  In  a  few 
minutes  a  very  marked  capillary  injection  appeared  in  the 
palms  of  her  hands,  her  face  and  the  back  of  her  neck.  At 
the  same  time  two  attacks  of  uticaria  came  on  at  intervals  of 
eight  minutes,  and  were  gone  in  five  minutes  after  the  first 
appearance  of  the  rash.  Half  an  hour  after  the  operation  a 
chill  supervened,  lasting  fifteen  minutes.  Before  the  opera- 
tion the  pulse  was  108.  After  the  milk  was  injected  it  ran 
up  to  150,  being  128  when  the  uticaria  appeared.  Two  hours 
and  a  half  after  the  injection  the  temperature  ran  suddenly 

134 


Miscellaneous.  135 

up  to  103°  F.,  and  then  fell  again.  The  patient  passed  a 
very  comfortable  night. 

June  25th. — No  marked  improvement. 

June  27th. — The  patient  was  again  operated  upon,  the  same 
quantity  of  milk  being  injected.  Previous  to  the  operation 
20  grains  of  quinia  were  given.  [This  same  amount  of 
-juinia  had  been  administered  previous  to  the  first  operation.] 
No  sooner  had  a  fluid  drachm  of  milk  entered  the  circulation 
than  great  capillary  congestion  followed,  and  the  patient  com- 
plained of  bursting  pain  in  her  head.  A  severe  cramp  seized 
her,  and  in  the  course  of  fifteen  minutes  her  menses  appeared. 
Again  two  attacks  of  uticaria  supervened. 

June  29th. — The  patient  was  much  stronger. 

July  17th. — Milk  to  the  amount  of  6  fluid  ounces  was 
again  injected.  The  injection  was  followed  by  the  same  symp- 
toms. From  that  date  the  patient's  condition  steadily  im- 
proved. She  gained  in  color,  and  her  nervous  phenomena 
disappeared  entirely. 

THE  ASSIMILATION   OF  COD-LIVER  OIL. 

Some  months  ago  Dr.  Wm.  H.  Bennett  instituted  a  series 
of  experiments  regarding  the  assimilation  of  cod-liver  oil  by 
the  system.  The  stools  of  a  number  of  patients,  placed  upon 
the  daily  use  of  this  article,  were  carefully  examined,  and  it 
was  found  that  in  the  majority  of  cases  these  stools  were  oily, 
showing  that  the  cod-liver  oil  had  simply  passed  through  the 
alimentary  canal  without  absorption.  Where  the  stools  were 
oily  the  patients  appeared  to  have  derived  no  benefit  from  the 
use  of  the  oil ;  but  in  the  few  cases  where  the  stools  were  not 
oily,  and  where  the  oil  had  consequently  been  absorbed,  the 
patients  had  grown  fat. 

Quite  recently  Dr.  Milton  Miller,  the  medical  resident, 
at  the  Episcopal  Hospital,  has  conducted  a  second  series  of 
experiments  of  the  same  nature,  and  has  obtained  like  results. 


136  Notes  of  Hospital  Practice. 

SLEEPLESSNESS   IN   UTERINE    DISORDERS. 

When  patients  complain  of  nervousness  or  of  sleeplessness*, 
the  bromide  of  potassium  is  given  either  alone  or  in  combina- 
tion. A  cheap  and  efficient  mixture  is  the  following: 

R     Pulv.  ferri  sulph.  exsic gr.  xxx. 

Potassii  bromid. 

Had.  coiumbse  contus ^ aa     %j. 

Aquae  bullientis .Oj. 

Steep  for  24  hours  and  then  strain. 

SIG. — One  tablespoonful  in  a  wineglassful  -of  water  just  before  or  just 
after  each  meal. 

In  other  cases  the  following  is  used : 

R     Elixir,  humuli - f^j. 

Elixir,  ammon.  valerian. 

Syrupi  lactucarii aa    f^ss.         M. 

SlG. — One  dessertspoonful  at  bedtime,  or  during  the  day  when  needful. 
—Dr.  -OooddL 

ATROPIA   AS   A   PREVE1STTIVE    OF   PY.EMIC  CHILLS. 

In  several  instances  of  abscess  of  the  liver  and  of  pyaemia, 
Dr.  Starr  administered  the  I/QQ  of  a  grain  of  atropia  by  hypo- 
dermic injection,  and  the  1/60  of  a  grain  internally,  to  prevent 
the  distressing  chills  consequent -upon  these  conditions.  This 
remedy  acted  like  a  charm.  The  effects  of  the  dose  or  hypo- 
dermic injection  given  in  the  morning  lasted  through  the  fol- 
lowing twenty-four  hours.  The  same' was  the  case  with  the 
belladonna-bath  (tr.  belladon.,  f  3  ij ;  spts.  frumenti,  f3ij; 
aquae,  f  ij.  SIG. — To  be  applied  to  the  whole  surface  of  the 
body  by  sponge  at  bedtime.) 

DIGITALIS  BY   HYPODERMIC   INJECTION. 

Dr.  Starr  has  recently  been  employing  digitalis  hypodermi- 
cally  with  much  success  in  cases  of  advanced  phthisis  and  of 
heart  failure.  The  injections  at  first  contained  gtt.  v  of  the 
tincture  of  digitalis  and  TT[,x  of  water.  Tlie  effects  being 


Miscellaneous.  137 

negative,  the  amount  of  the  digitalis  was  increased  to  gtt.  x, 
with  the  most  decided  effects.  The  pulse  fell  at  once  from 
120  to  105  in  the  minute.  At  one  time  as  much  as  gtt.  xv 
of  the  digitalis  were  injected  with  great  advantage. 

OPHTHALMIA   NEONATORUM. 

A  solution  of  nitrate  of  silver  (f  of  a  grain  to  the  ounce)  is 
injected  under  the  lids  twice  a  day. 

For  the  lids  themselves  the  following  is  usually  employed  : 

li     Sodae  boratis gr.  xij. 

Zinci  sulphatig gr.  j 

Aquse  camphore f."j. 

Aquae  clestillatae fjfj.        M. 

Sio. — To  be  applied  to  the  fids  two  or  three  times  a  day. 

A  plan  of  treatment  highly  recommended  by  Mr.  Dickson, 
of  London,  viz.,  the  injection  between  the  lids  every  half-hour 
of  a  solution  of  alum  (from  5  to  8  grains  to  the  ounce),  the 
strength  of  the  solution  to  be  gradually  diminished  as  the  case 
gets  better,  has  also  been  tried  with  very  gratifying  results  by 
Dr.  J.  F.  Meiga, 


INDEX. 


Abortion 97-100 

Abscesses,  The  Hyperdistension 

of 71 

Acne  Rosacea 37-38 

Addison's  Disease 41-42 

Amenorrhcea 104-105 

Anaemias,  The  Intravenous  In- 
jection of  Milk  in  Functional 

and  Organic ..134-13*5 

Anaemia  and  Chlorosis 90-92 

Aneurism 54-55 

Angina,  Acute 47 

"      ,  Pseudo-Membranous..! 9-21 

Aorta,  Constriction  of. _..43-45 

Aortic  Valve,  Patulous,  Accom- 
panying Chronic  Bright's  Dis- 
ease  -...32-33 

Apoplexy 116 

Artli  ri  tis,  Rheumatoid .  ..33-37 

Atropia  as  a  Preventive  of  Pyse- 
mic  Chills 136 

B. 

Brain,  Unique  Case  of  Injury  to 

the 78-81 

Brain,  Compression  of  the 81-82 

Brain    Disease,    Treatment    of 

Syphilitic 114-115 

Breasts,  Gathered 100-101 

Bright's  Disease,  Patulous  Aor- 
tic Valve  Accompanying 

Chronic 32-33 

Burn  followed  by  Contraction  of 
Tissue...,  ....72-73 


O. 

Calabar  Bean  in  Dementia  Para- 

lytica 116 

Cancer,  Epithelial 82 

Catarrh,  Post-Nasal 51-52 

Cautery,  The  Actual 114 

Celluiitis,  Pelvic  Peritonitis  and, 

85-86 
Cerebral  Exhaustion,  Treatment 

of 115 

Cervix  Uteri,  Cancer  of. 106 

"    ,  Conical 107 

Chills,   Pysemic,   Atropia  as    a 

Preventive  of. 136 

Chlorosis,  Anaemia  and 90-92 

Chorea 121 

Clavicle,  Fractured 65  and  81 

Cod  Liver  Oil,  The  Assimilation 

of 135 

Collapse « - 47 

Constipation,  Habitual  with  Fis- 
sure of  Rectum 104 

Cystitis  in  the  Female 106-107 

«          "      Mate 66-68 

D. 

Dementia    Paralytica,    Calabar 

Bean  in 116 

Diabetes  Insipidus 51 

"       ,  Saccharine 40-41 

Digitalis  by  Hypodermic  Injec- 
tion  136-137 

Douglas'  Pouch,  Hsematoma  in,     87 

Dropsy,  Tapping  in 70 

Dysentery,  Acute  and  Chronic, 

48-49 


140 


INDEX. 


Dysmenorrhcea 95 

Dyspepsia 49-51 

E. 

Eczema,  Chronic 33-37 

Electricity 110-111 

Elephantiasis    Arabum,    Nerve 

Section  for , 61-64 

Endometrium,  Fungous  Granu- 
lations of 108 

Erysipelas 83 

Eustachian  Tubes,  Inflammation 

of 28-29 

Exhaustion,  Sexual 132 

P. 

Fever,  Contagion  in  Scarlet 30-31 

"      Pleuro  -  Pneumonia   fol- 
lowing Typhoid 12-15 

Fever,  Puerperal 94-95 

"     Typhoid,  Some  cases  of, 
and  their  treatment 5-10 

Fever,  Typhoid,  some  interesting 
points  in  the  Diagnosis  and 
Prognosis  of 3-5 

Fever,  Typhoid,  the  treatment 
of. 10-12 

Fever,  Thermic 46 

Fistula,  Vesico- Vaginal,  Closure 
of  Vulva  for 108 

Fracture  below  the  Knee,  Ex- 
tension in 81 

Fracture,  Intracapsular 81 

Frontal  Bone,  Rapid  Recovery 
from  Depressed  Fracture  of,  71-72 

Funifl,  The  Treatment  of  the 100 

G. 

General  Notes 116 

Gleet 64 

Goitre 49 

Gonorrhoea  in  the  Male 73 

Graves'  Disease....  ...  27-28 


Haemoptysis 40 

Heart  Disease,  The  Treatment 

of  Organic 17-19 

Heart,  Hypertrophy  of. 43-45 

Hemorrhage,  Post-Partum 88-90 

Hemorrhoids,  External 70 

Hernia,  Temporarily  Irreduci- 
ble  77-78 

Hip-joint  Disease 61 

I. 
Influenza 55 

K. 

Kidneys,  Albuminoid  Degene- 
ration of. 19-21 

L. 
Lumbago 52 

M. 

Massage  and  Swedish  Move- 
ment  113-114 

Menopause,  The 92-93 

Metal  oscopy  and  Metalotherapy, 

111-113 

Middle  Ear,  Inflammation  of 
the 28-29 

Milk,  Intravenous  Injection  of, 
in  Functional  and  Organic 
Anaemias 134-135 

N. 

Naevus  Materna 69-71 

Nasal  Passages,  Inflammation  of, 

28-29 
Nephritis,   Acute   and   Chronic 

Tubal 56 

Nephritis,  Chronic  Interstitial...     56 
Nipples,  Sore 101-102 

O. 

Ophthalmia  Neonatorum 1 37 

Opium  Habit,  The 54 

Ovarian  Cyst,  Diagnosis  of 95-96 


141 


Ovaries,  Prolapse  of  the 107 

Ovariotomy 101 

Ozena ...19-21 

P. 

Palsy,  Iron  Pullers'...^ 123-126 

"       Violinists' .,123-126 

"       Weavers' ...123-126 

Paracentesis    Thoracis,  Indica- 
tions against 15-16 

Paralysis,  Facial,  Followed  by 

Secondary  Spasms, -etc 126-129 

Paralysis,  with  Loss  of  Hearing, 

etc „ 129-131 

Paraphimosis — 84 

Paraplegia    due    to    a  ..Spinal 

Sprain „ 132-133 

Patella,  Fractured 60 

Perimetritis 87-88 

Perinseum,  Laceration  of  the...96-97 
Peritonitis  and  Cellulitis,  Pelvis, 

85-86 

Peritonitis  Idiopathic 21-23 

Perityphlitis „ 42-43 

Phthisis,  Laryngeal 52-54 

"       ,  Nigtf  Sweats  in 29 

Placenta  Praevia „  102 

Pneumonia « . 16-17 

Psoriasis,  Cl.ronic .,     42 

Pregnancy,  The  Diagnosis  of,  93-94 

"         ,  The  Vomiting  of....     87 

Prostatorrhoea  with  Stricture...68-69 

B. 

Rectum,   Fissure   of  .the,  with 

Habitual  Constipation 104 

Recurrent  Laryngeal  Nerve,  Pa- 
ralysis of 122 

Rheumatism,  Acute  and  Chronic, 

47-48 
S. 

Sciatica 38-40 

Shock,  Surgical 65 

Sore  Throat,  Syphilitic 76-77 


Spine,  Curvature  of  the 65 

Spinal  Disease,  Three  Interest- 
ing cases  of..... 116-121 

Spinal  Accessory  Nerve,  Spasm 
of  the. 131 

Spinal  Exhaustion,  The  Treat- 
ment of. .. 115 

Spinal  Sclerosis,  The  Treatment 
of. 115 

Spinal  Sprain,  Paraplegia  due  to 
a 132-133 

Sprains ^ „ 73 

Stomach,  Dilatatiqn  of  the 37 

"       ,  Ulcer  of  the 51 

Stricture.... 74-76 

"        with  Prostatorrhoea....68-69 

Swedish    Movements,    Massage 
and. ..113-114 

Syphilis,  Diagnosis  of  Congeni- 
:tal 102-104 

T. 

Tetanus ... 123 

Tinea  Favosa 38 

Toe-Nail,  Ingrowing 82-83 

Tonsillitis,  Acute 46 

U. 

Ulcers 65 

.Uraemia 56 

Urethra,  Foreign  Body  in 57-59 

"      ,  Caruncle  of 105-106 

Uterine   Disease,    Sleeplessness 

in 136 

Uterus,  Anteflexion  of. 86-87 

V. 

^Vaginiemus 109 

Vaginitis 108 

Vertigo,  Gastric 41 

Vomiting,  Two  Interesting  Cases 

of 23-27 

Vulva,  Closure  of  the,  for  Vesi- 

co-Vaginal  Fistula 108 


NOTES 


OF 


HOSPITAL  PRACTICE 


PART  II. 


NEW  YORK  HOSPITALS. 


EDITED   BY 


SAMUEL  M.  MILLER,  M.  D, 


PHILADELPHIA,  PA. 
SAMUKL  M.  MILLER,  M.  D.,  Publisher. 

1880. 


GENERAL  DISEASES. 

ACUTE  PNEUMONIA. 

Dr.  Alonzo  Clark  has  not  lost  a  fondness  for  the  lancet  in 
pneumonia.  He  is  accustomed  to  use  cups  after  scarification, 
taking  three,  four,  or  five  ounces  from  the  affected  side.  He 
does  not  place  any  confidence  in  the  calomel  treatment,  or  in 
Laenuec's  treatment  by  tartar  emetic,  but  is  satisfied,  when  the 
temperature  rises  to  105°  or  106°,  that  the  safest  and  most 
efficient  medicine  is  quinia,  given  in  doses  of  10  grains  thrice 
daily.  The  application  of  cold  to  the  surface  of  the  body  is 
thought  to  be  disastrous.  Dr.  Clark  does  not  allow  any  ice 
to  be  applied  to  any  patient  of  his  who  has  pneumonia.  He, 
however,  regards  sponging  with  cold  water  as  admissible,  and 
is  in  favor  of  the  employment  of  a  bath  at  a  temperature  20° 
below  that  of  the  body.  His  objection  to  veratrum  viride  is 
that,  when  it  is  given  with  any  freedom,  it  is  very  apt  to  lead 
to  collapse ;  aconite,  he  thinks,  safer.  He  regards  the  alco- 
holics as  utterly  useless  in  the  treatment  of  this  affection. 

Ten  years  ago,  at  Bellevue  Hospital,  pneumonia  was  quite 
uniformly  treated  with  carbonate  of  ammonium,  internally, 
and  an  oil-silk  jacket,  externally.  The  carbonate  was  given 
in  doses  of  gr.  v  every  three  hours,  or  sometimes  gr.  x  thrice 
daily.  The  muriate  was  occasionally  substituted.  Gradually, 
quinia  came  to  be  combined  with  the  ammonium,  while  to- 
day, quinia  has  entirely  taken  its  place  in  many  wards.  The 
quinia  is  given  in  doses  of  gr.  x  thrice  daily,  increased  or 
diminished  according  to  the  fever.  The  oil-cloth  jacket  is 
still  continued,  and,  if  there  is  much  pain  in  the  side,  a  coat 
of  iodine  is  ordered.  This,  with  an  absolutely  recumbent 

(1) 


2  Notes  of  Hospital  Practice. 

posture,  is  all  that  is  enjoined  in  many  cases.  Aconite  has 
been  used  in  five  cases,  of  which  one  died.  It  is  given  in 
doses  of  Ity  every  hour,  until  some  effect  of  the  drug,  either 
in  the  relief  of  dyspnoea  or  fever,  or  the  production  of  sweat- 
ing, is  brought  about. 

In  44  cases,  quinine  was  used  with  good  results.  The 
method  of  administration  is  varied.  Besides  the  routine  men- 
tioned, it  is  given  gr.  j  every  hour,  or  gr.  v  every  four  hours, 
or  often  gr.  xl  or  gr.  1,  in  one  dose,  then  discontinuing  it  for 
a  day  or  more.  The  antipyretic  effect  of  quinine  has  not 
been  sufficiently  marked  to  make  it  clear  which  is  the  best 
way.  Cold  sponging  has  been  employed  with  quinine.  Of 
seven  cases  so  treated,  three  died.  The  gradually-cooled  bath 
has  been  used,  and  was  at  once  given  up. 

Many  cases  that  have  been  admitted  into  the  hospital  have 
had  a  record  like  the  following :  The  patient  is  a  tolerably 
strong  man,  in  the  third  day  of  the  fever.  He  has  a  tem- 
perature of  104°,  respiration  50.  His  pulse  is  very  good,  and 
he  feels  pretty  comfortable.  He  is  given  milk  and  eggs,  and 
gr.  xv  of  quinine.  This  is  in  the  morning.  In  the  afternoon 
he  is  weaker,  his  face  is  a  little  blue,  he  breathes  faster.  On 
listening  to  the  lungs,  moist  rales,  fine  and  coarse,  are  heard. 
He  is  beginning  to  have  oedema.  He  is  at  once  dry-cupped 
for  fifteen  or  twenty  minutes,  during  which  time  150  cups  are 
put  on.  The  oedema  has  now  disappeared.  He  is  ordered 
fn  x  of  tr.  digitalis  every  three  hours,  and  f  ss  of  whiskey 
every  two  hours,  with  milk  and  eggs.  He  continues  better 
for  some  hours.  Towards  evening  the  oedema  again  shows 
itself.  He  is  again  cupped,  and  gr.  x  ammon.  carb.  is  ordered 
every  two  hours,  alternating  with  the  whiskey.  Again  the 
oedema  clears  up.  In  addition,  a  can  of  oxygen  is  ordered 
for  the  night,  and  the  patient  inhales  it  for  15  minutes  in 
every  hour.  This  relieves  his  dyspnoea.  But,  towards  morn- 
ing, the  cyanosis  and  oedema  again  appear.  The  cups  are 
applied  again,  and  the  whiskey  ordered,  §  ss  every  hour,  alter- 
nating with  the  ammonia,  gr.  x  every  hour.  By  these  mea- 


General  Diseases.  3 

sures,  he  is  carried  through  the  night,  and  in  the  morning  is 
easier.  Nourishment  in  the  form  of  milk  is  still  kept  up. 
He  is  not  allowed  to  sleep  continuously,  for,  during  sleep,  the 
oedema  comes  on.  By  such  fighting  as  this — -the  greatest  reli- 
ance being  placed  on  whiskey,  milk,  and  dry  cups — a  patient 
is  occasionally  brought  through.  If,  on  the  following  day, 
he  is  still  worse,  the  resources  in  the  way  of  stimulants  are 
not  exhausted.  Other  forms  of  ammonia  are  used.  Hypo- 
dermic injections  of  camphor  dissolved  in  sweet  oil,  are  given 
every  three  hours,  in  4-grain  doses.  If  the  patient  has 
persistent  oedema  and  a  full  pulse,  venesection  is  tried,  and  is 
invaluable  when  digitalis  and  cups  no  longer  avail.  The 
oxygen  cannot  be  pushed  too  much,  as  it  causes  unconscious- 
ness. 

Hypodermic  injections  of  ether  to  the  amount  of  1  or 
2  drachms,  sometimes  bring  up  the  pulse.  Teaspoonful 
doses  of  champagne  every  five  minutes,  will  help  to  tide  a 
crisis.  There  is  a  limit  to  stimulation,  of  course.  When 
|  ss  of  whiskey  every  half  hour  has  no  effect,  the  patient 
will  die. 

It  will  be  seen  that  no  new  or  specific  treatment  can  be 
deduced  from  these  cases.  It  has  become  a  firmly-rooted 
belief  that  quinine  is  a  good  thing  to  give,  and  in  those  so 
treated,  the  mortality  has  been  somewhat  diminished.  The 
class  of  patients  is  not  one  upon  which  cardiac  sedatives  can 
be  fairly  tried. 

Dr.  Austin  Flint  treats  pneumonia  by  rest  in  bed  and  the 
administration  of  half  an  ounce  of  whiskey  every  two  hours, 
with  milk  for  nourishment.  When  the  action  of  the  heart  is 
iveak  and  irregular,  digitalis  is  administered  in  doses  of  H^xx 
of  the  tincture  three  times  a  day. 

EMPYEMA. 

In  all  cases  of  empyema  Dr.  Alonzo  Clark  expects  to  punc- 
ture several  times.  His  practice  is  to  incise  the  skin,  plunge 


4  Notes  of  Hospital  Practice. 

in  a  trocar  and  canula,  and  after  withdrawing  these  instru- 
ments, insert  into  the  opening  thus  made  a  linen  tent,  which 
he  fastens  by  its  free  ends  to  the  chest  by  means  of  adhesive 
strips.  This  teat  is  removed  every  day  or  two  to  allow  the 
pus  to  run  out.  Dr.  Clark  is  also  very  partial  to  Dr.  Wy man's 
method,  as  practiced  by  Dr.  Bowditch,  of  Boston.  This  con- 
sists in  the  use  of  the  exhausting  pump,  and  for  this  purpose 
he  likes  the  ordinary  stomach  pump.  He  uses  an  extremely 
small  trocar,  and  a  common  exploring  needle,  which  he  regards 
as  a  good  instrument  for  this  purpose,  or  better  still,  the  aspira- 
tor with  a  fine  trocar.  Before  introducing  the  instrument  he 
considers  it  well  to  benumb  the  part  by  firm  pressure  with  the 
finger.  In  these  cases  he  has  not  found  it  necessary  to  use  the 
scalpel  as  when  a  large  trocar  is  used.  After  the  trocar  has 
been  withdrawn  the  canula  is  pressed  in  some  distance,  as  it 
will  not  hurt  the  lung  if  it  touches  it  The  piston  is  worked 
slowly.  As  the  opening  thus  made  is  small  it  closes  itself  to 
the  exclusion  of  air  as«oon  as  the  canula  is  withdrawn.  Dr. 
Clarks  regards  this  last  method  as  peculiarly  desirable  before 
it  has  been  ascertained  that  the  effusion  is  purulent  by  a  pre- 
vious operation.  When  it  is  known  that  the  cavity  contains 
pus,  Dr.  Clark  does  not  pretend  to  choose  between  the  two 
methods.  He  continues  to  draw  off  fluid  until  oppression  is 
felt  at  the  %tern\vm,  and  guards  against  drawing  off  too  much 
for  fear  of  making  a  vacuum,  too  great  for  the  comfort  of  the 
patient.  When  the  operation  is  performed  in  front  it  is  done 
between  the  sixth  and  seventh  rib,  to  avoid  wounding  the 
diaphragm.  On  the  side  he  selects  a  spot  between  the  seventh 
and  eighth  rib,  and  in  the  back  between  the  eighth  and  ninth 
rib.  He  thinks  that  iodine  injections  for  the  prevention  of 
further  effusion  of  pus  are  attended  with  more  harm  than 
good.  If  injections  of  any  sort  are  to  be  used  he  prefers 
simple  warm  water.  Tonics  he  regards  as  more  or  less  ser- 
viceable, and  this  he  thinks  is  about  all  that  can  be  done  in 
the  way  of  treatment.  Even  under  the  best  management  he 
expects  half  of  these  patients  to  die. 


General  Diseases.  5 

DIPHTHERIA. 

Dr.  C.  E.  BiiliugtoD  recommends  the  following  prescrip- 
tions : 

No.  1.     Iron  and  Glycerine  Mixture. 

R      Tinct.  ferri  chloridi ~.~ f£j. 

Glycerinae, 

Aquae. ~ aa  f^j.  M. 

Sio. — A  teaspoonful  of  this  and  «f  No.  2,  alternately,  every  half  hour 
through  the  day. 

No.  2.  -Chlorate  of  Pota&swm  Mixture. 

R      Potassii  chlorat ~. Jss. 

Glycerinse. ~ „« fsss. 

Aquae  calcis. ......~ f^  ijss.          M. 

Sio. — A  teaspoonful  of  .this  and  of  No.  1,  alternately,  every  half  hour 
through  the  day. 

No.  8.    Spraiy  Misctwe. 

R      Acid,  carbol ~.  TT^v. 

Aquae  calcis ~ f^  vj.  M. 

Sio. — To  be  used  with  a  small  haad  atomizer. 

The  patient  is  allowed  to  sleep  for  an  hour  or  two  at  a  time 
at  night.  When  awake,  doses  ef  No.  1  and  2  are  alternated 
every  half  hour.  The  throat  is  sprayed  with  No.  3  for  several 
minutes  at  a  time,  whenever  Nos.  1  and  2  are  given.  In 
spraying,  the  mouth  is  opened  widely. 

Where  there  is  nasal  implication  the  nose  is  thoroughly 
syringed  out  with  warm  or  tepid  salt-water,  once,  twice  or 
three  times  a  day.  This  syringing  is  done  with  the  patient's 
head  inclined  forward,  a  two-ounce  hard-rubber  ear  syringe  is 
used. 

Dr.  Billington  never  applies  any  brush  or  swab  to  the 
throat.  He  sometimes  throws  a  drachm  of  No.  1,  with  a 
syringe,  directly  against  the  affected  surface  in  the  throat. 
He  does  not  give  quinia  or  any  other  unpleasant  medicine  to 
children.  He  does  not  give  alcoholic  stimulants  except  where 


6  Notes  of  Hospital  Practice. 

a  child,  who  cannot  be  induced  to  take  other  nourishment,  will 
take  weak  milk-punch  or  egg-nog. 

The  patient  is  nourished  with  an  abundance  of  cold  milk, 
given  frequently,  to  which  a  little  lime-water  is  often  advan- 
tageously added.  When  the  stage  of  extreme  exhaustion  has 
been  reached  in  bad  cases  the  juice  squeezed  from  beek-steak 
is  given. 

ASTHMA. 

Among  the  means  by  which  asthmatic  attacks  are  treated 
by  Dr.  Clark,  is  the  inhalation  of  the  smoke  of  dry  stramonium 
leaves,  or  else  he  orders  a  piece  of  bibulous  paper  to  be  dip- 
ped into  a  solution  of  the  nitrate  of  potassium  until  it  becomes 
pretty  well  filled  with  nitre.  This  paper  is  then  dried  and  a 
small  piece  of  it  is  burnt,  and  the  sufferer  inhales  the  fumes. 
The  most  efficacious  remedy  for  allaying  the  spasms,  of  which 
he  knows,  is  the  inhalation  of  the  nitrite  of  amyl.  This  drug 
will  stop  the  individual  attacks,  but  will  not  cure  the  disease. 
Dr.  Clark  recognizes  but  one  radical  cure  for  asthma,  and 
that  is  the  iodide  of  potassium.  One-half  of  his  patients  are 
cured  by  it. 

SUB- ACUTE  PLEURISY. 

Dr.  Clark  aims,  on  the  one  hand,  at  subduing  the  inflamma- 
tion, and  on  the  other,  at  promoting  absorption  of  the  fluid. 
Bleeding  from  the  arm  he  regards  unnecessary,  but  when 
he  is  called  at  an  early  stage,  which  is  seldom  the  case,  he 
advises  the  use  of  cups,  and  repeats  them  as  often  as  necessary. 
He  thinks  that  cups  have  great  influence  over  recent  inflamma- 
tions, but  that  they  do  little  good  in  sub-acute  and  chronic 
inflammations.  As  in  other  sub-acute  inflammations,  blisters 
are  applied,  and  in  doing  this  he  selects  three  spots,  one  being 
placed  on  a  new  spot  as  the  last  has  healed.  He  scarcely  ever 
finds  that  more  than  three  are  required.  Among  active 


General  Diseases.  7 

diuretics,  he  prefers  potassii  iodidi,  gr.  xxx  per  day.     If  this 
does  not  subserve,  he  tries  the  following : 

&     Potas.  acet., 

Inf.  digitalis aa  f^ij-iv. 

Each  day. 
Or: 

R     Pulv.  dig., 

Pulv.  sallse  mer., 

Hydrarg.  chlo.  rait. aa  gr.  z.          M. 

Et  ft.  pil.  No.  x. 
Sio. — One  pill  thrice  daily. 

He  uses  this  until  the  effect  of  the  mercury  is  produced, 
and  then  tries  potass,  iod.  again.  In  some  cases  he  finds  that 
mild  counter-irritants,  such  as  the  ammoniacal  liniment,  an- 
swer, as  in  nervous  women,  but,  as  a  rule,  he  does  not  trust 
to  these.  Purgatives  and  vapor-baths,  he  sometimes  finds 
useful.  This  treatment  he  thinks  will  suffice  in  ordinary  sub- 
acute  pleurisy,  but  when  all  these  measures  fail,  he  claims  that 
we  have  but  two  resources — to  do  nothing  or  to  use  the  trocar. 
Some  physicians  advise  the  early  use  of  the  trocar,  but  from 
fear  of  changing  the  serous  effusion  to  pus,  he  does  not  like 
the  practice.  In  some  cases  he  is  forced  to  use  the  trocar,  but 
always  uses  medical  means  beforehand,  if  the  patient  is  not 
rapidly  sinking. 

CHRONIC  SUPPURATIVE   INFLAMMATION  OF  THE   MIDDLE 

EAR. 

Dr.  O.  D.  Pomeroy  regards  cleanliness  as  the  chief  item  of 
treatment.  He  does  not  approve  of  the  syringe  as  a  means  of 
cleansing  the  ear,  but  makes  use  of  cotton  wool.  In  some 
cases,  however,  where  the  amount  of  the  discharge  is  very 
great  he  is  compelled  to  employ  the  syringe.  After  the  ear 
has  been  cleansed  he  uses  astringents  in  the  shape  of  nitrate 
of  silver.  To  apply  this  astringent  properly  he  makes  use  of 
a  dropping  tube  which  consistsof  a  hard-rubber  catheter  with 


8  Notes  of  Hospital  Practice. 

a  soft  rubber  thimble  upon  its  ring  extremity.  From  three 
to  six  drops  of  the  astringent  solution  are  thrown  into  the  ear 
with  some  little  violence,  then  drawn  out,  and  the  process 
repeated  several  times  while  the  dropping  tube  is  still  inserted 
in  the  ear.  If  the  perforation  in  the  drum  membrane  is  small, 
and  if  it  is  evident  that  there  are  extensive  purulent  processes 
going  on  in  the  tympanum,  Dr.  Pomeroy  does  not  hesitate  to 
make  an  incision  in  the  membrane,  so  that  the  astringent  can 
be  effectively  introduced.  The  solution  of  nitrate  of  silver 
used  has  a  strength  ranging  from  10  grains  to  the  ounce,  all 
the  way  to  480  grains  to  the  ounce.  This  saturated  solution 
has  been  employed  upon  several  occasions  without  causing  any 
pain  or  discomfort.  The  rule  adopted  is  that  the  solution 
used  should  never  be  strong  enough  to  give  rise  to  pain. 

Where  there  is  evidence  of  purulent  inflammation  of  the 
tympanic  cavity  without  perforation,  a  strong  solution  painted 
upon  the  drum  membrane  has  frequently  been  found  to  arrest 
the  purulent  process. 

With  regard  to  the  use  of  other  astringents  the  objection 
urged  against  alum  is  that  it  forms  alum-curds  which  act  as 
foreign  bodies  in  the  tympanic  cavity.  Acetate  of  lead,  has 
been  occasionally  employed  by  Dr.  Pomeroy  in  solutions  of 
from  2  to  10  grains  to  the  ounce.  Carbolic  acid  has  the 
additional  value  of  being  a  disinfectant.  The  solutions  em- 
ployed vary  in  strength  from  2  to  4  grains  to  the  ounce. 

Where  there  is  a  relaxed  condition  of  the  lining  membrane 
of  the  tympanum  the  cavity  is  packed  as  full  as  possible  with 
absorbent  cotton. 

Dr.  Pomeroy  does  not  believe  in  artificial  drum  membranes, 

He  recommends  his  patients  to  wear  cotton  in  their  ears 
until  cured.  The  cotton  is  placed  loosely  in  the  ear  and 
removed  as  often  as  it  becomes  in  the  least  moist. 

Granulations  or  polypi  are  treated  by  removing  them  with 
the  forceps.  Small  nasal  forceps  have  been  found  to  answer 
tfiis  purpose  very  well.  A  speculum  is  avoided,  if  possible, 
but  may  be  used  to  good  advantage  where  the  polypus  is 


Crenera/  Diseases.  9 

small.  Hemorrhage  from  the  root  of  the  polypus  is  con- 
trolled by  means  of  nitrate  of  silver  or  liquor  ferri  persul- 
phatis. 

After  removing  the  polyp  the  completion  of  the  cure  ie 
effected  by  means  of  cauterization  with  nitrate  of  silver.  For 
this  purpose  a  saturated  solution  of  the  crystals  is  employed. 
The  method  is  to  take  a  fine  probe,  wind  the  tip*  with  a  piece 
of  cotton,  dip  it  in  the  solution,  remove  the  excess  by  wiping 
on  blotting  paper,  and  then  apply  it  to  every  remaining  por- 
tion of  the  polypus  until  it  is  completely  whitened.  Th« 
strongest  nitric  acid  is  sometimes  used  instead  of  the  nitrate  of 
silver,  but  is  applied  more  carefully.  In  some  instances  burnt 
alum  and  iodiform  have  been  of  valuable  assistance  in  remov- 
ing granulations  and  bases  of  polypi.  Sequestra  are  removed 
with  the  forceps  or  chopped  away  by  means  of  a  dentist's  drilL 

ACUTE  PLEURISY. 

This  disease,  according  to  Dr.  Clark,  is,  by  common  consent, 
better  controlled  by  the  lancet  tlian  any  other  serous  inflam- 
mation. He  applies  cups  with  scarification,  to  the  affected 
side,  and  repeats  them  two  or  three  times,  after  proper  inter- 
vals. When  the  pain  has  subsided,  blisters  are  applied,  to 
overcome  whatever  inflammation  remains.  The  treatment, 
then,  adopted  by  him  is  decidedly  antiphlogistic,  so  as  to  pre- 
vent abundant  effusion.  He  believes  that  there  is  no  occasion 
for  diuretics.  He  makes  use  of  diaphoretics  in  the  latter 
stages.  Fomentations  of  warm  water,  and  the  like,  are  some- 
times applied  to  the  affected  side.  Not  much  constitutional 
treatment  is  required.  Dr.  Clark  claims  that  the  membrane, 
in  cases  which  i^over,  is  left  and  is  organized,  and  that  con- 
traction of  side  and  shortness  of  breath  will  occur  in  every 
form  of  pleurisy,  but  that  this  does  not  take  place  until  sev- 
eral weeks  after  the  attack,  and  continues  for  three  or  four 
years,  during  which  time  the  membrane  becomes  absorbed. 


10  Notes  of  Hospital  Practice. 

VOMITING   IN   PHTHISIS. 

When  caused  by  pressure  of  the  enlarged  bronchial  glands 
upon  the  par  vagum,  in  the  early  stage  of  phthisis,  it  is 
arrested,  in  the  wards  of  the  Roosevelt  Hospital,  by  the 
application  of  dry  cups  between  the  scapulae.  Carbolic  acid 
is  prescribed;  to  remove  the  vomiting  consequent  upon  the 
offensive  taste  and  odor  of  the  expectoration. 

DIARRHOEA   OF   PHTHISIS. 

When  this  symptom  is  present,  the  patients  in  Roosevelt 
Hospital  are  fed  upon  milk  boiled  with  mutton  suet  until  it 
is  as  thick  as  cream.  A  piece  of  suet  is  put  in  a  bag  and 
boiled  in  milk  until  the  requisite  consistency  is  obtained. 

The  following  pill  has  been  used  with  excellent  results,  in 
these  cases : 

H     Kesin.  terebinth gr.  iij. 

Argenti  nitrat., 

Opii aa  gr.  J  M. 

Sio. — One  pill  when  needed. 

APHTHA   OF   PHTHISIS. 

The  following  mixture  is  used  at  the  Roosevelt  Hospital. 
The  patient  may  either  apply  it  with  a  brush  or  rinse  his 
mouth  with  it : 

R     Quinae  sulph gr.  j. 

Olei  piperis  nigris gtt.  j. 

Aquae f|j.  M. 

0 

SORE  THROAT   OF   PHTHISIS. 

For  the  relief  of  this  condition,  salt-water  and  oil  of  black 
pepper,  in  spray,  are  used  at  the  Roosevelt  Hospital.  The 
solution  of  salt  is  no  stronger  than  that  made  by  adding  a 


General  Diseases.  11 

teaspoonful  of  common  salt  to  a  pint  of  water.  The  oil  of 
black  pepper  is  added,  in  the  proportion  of  1  drop  to  the 
ounce. 

JAUNDICE. 

Dr.  Clark  recommends  the  free  use  of  soda,  and  regards  it 
as  a  better  cholagogue  than  mercury.  The  form  of  soda  pre- 
scribed is  the  carbonate,  in  3  ss  doses,  thrice  daily.  It  is 
sometimes  taken  to  advantage  in  Vichy  water.  As  a  tonic, 
in  this  condition,  he  prefers  the  proto-carbonate  of  iron,  or 
the  chocolate  iron  lozenges. 


SPORADIC   PERITONITIS. 

Dr.  Clark  believes  that  under  proper  treatment  a  consider- 
able number  will  recover,  but  that  whatever  is  done  must  be 
done  with  energy,  as  the  natural  dilution  of  the  disease  is 
"four  days"  Blood-letting,  both  general  and  local,  he  prac- 
tices to  a  considerable  extent  in  the  treatment  of  this  disease. 
Dr.  Armstrong  proposed  blood-letting,  followed  by  a  full 
dose  of  opium,  as  the  latter  perpetuated  the  effect  of  the  bleed- 
ing ;  but  while  he  looked  upon  both  as  necessary,  if  he  could 
have  but  one,  he  preferred  the  opium.  Drs.  Palmer  and 
Child,  of  Vermont,  treated  their  patients  by  the  Armstrong 
method,  in  1844,  with  success.  When  Dr.  Clark  first  adopted 
this  mode  of  treatment,  eight  recovered,  the  ninth  died.  His 
rule  is  to  give  as  much  opium  as  the  patient  can  take  without 
being  narcotized,  beginning  with  gr.  ij— iv  every  two  hours, 
until  the  symptoms  of  narcosis  begin  to  show.  In  the  case  of 
a  hospital  patient,  gr.  iv  were  given,  and  the  dose  increased 
gr.  j  every  hour  until  a  gr.  xii  dose  was  taken.  One  objection 
to  this  plan  of  treatment,  according  to  Dr.  Clark,  is,  that  it 
requires  the  attention  of  the  physician,  who  should  always  ad- 
minister the  opium  himself.  It  is  not  important  which  prepa- 
ration of  opium  is  used,  but  it  is  important  that  the  same 


12  Notes  of  Hospital  Practice. 

should  be  used  from  beginning  to  end.  If  pills  are  used  they 
are  freshly  made  up  every  twelve  hours.  Opium  is  given  by 
its  effects  and  not  by  quantity ;  these  effects  are  sensible  con- 
traction of  the  pupils,  marked  reduction  in  the  frequency  of 
respiration,  diminished  frequency  of  pulse,  gentle  perspiration 
of  skin,  itching  of  the  mucous  membrane  of  the  nose,  and  easy 
but  very  much  protracted  sleep,  from  which  the  patient  can 
be  easily  aroused.  The  pain  first  disappears.  Tympanites 
continues  until  inflammation  is  subdued.  The  bowels  are  let 
atone  for  one  week  longer,  as  they  will  move  when  inflamma- 
tion subsides.  The  influence  of  opium  is  kept  up  until  peri- 
staltic action  is  re-established.  The  dose  is  then  diminished, 
and  when  a  spontaneous  movement  occurs,  it  is  suspended 
altogether.  A  full  dose  is  required  at  night  to  produce  sleep. 
Dr.  Clark  has  seen  peritonitis  from  perforation  cured  by 
opium.  No  other  mode  of  treatment  has  been  successful  in 
his  hands.  Strong  coffee  and  the  cold  effusions  are  used  by 
him  as  antidotes  in  poisoning  from  opium.  With  a  fair 
amount  of  caution  and  these  two  antidotes,  he  has  not  often 
lost  a  patient.  He  does  not  know  of  a  single  death  produced 
by  opium  in  this  disease. 

TREATMENT   OF  THE   PAINS   OF   LOCOMOTOR   ATAXIA. 

A  male  patient  in  Bellevue  Hospital,  set.  45,  had  locomotor 
ataxia,  and  suffered  from  excruciating  pains  in  his  limbs.  He 
had  no  double  vision,  but  had  slight  nystagmus.  There  was 
marked  delay  in  communication  of  sensation  to  the  brain 
from  the  feet,  five  or  six  seconds  passing  after  the  foot  had 
been  pricked  before  the  sensation  was  experienced.  There 
was  also  persistent  sensation,  the  pricking  being  felt  for  some 
time  after  it  had  been  done.  There  was  also  inability  to  locate 
impressions  correctly.  He  had  not  had  any  trouble  with  his 
bowels  or  bladder,  and  his  sexual  desire  and  capacity  were 
unimpaired.  There  was  no  tendon  reflex. 

By  the  pains,  he  could  predict  accurately  concerning  the 


General  Diseases.  13 

weather.  For  the  relief  of  the  fulminating  pains,  he  had 
resorted  to  the  actual  cautery,  a  variety  of  remedies — among 
them  gelsemium,  which  relieved  him  for  a  time — and  hypo- 
dermic injections  of  morphia.  The  hypodermic  injections 
impaired  his  nutrition  and  produced  delirium.  All  remedies 
used  were  discontinued,  and  for  them  the  bisulphide  of  carbon 
was  substituted,  and,  applied  to  the  spine,  gave,  as  the  patient 
claimed,  complete  relief  from  all  pain. 

LOBULAR  PNEUMONIA. 

This  condition,  Dr.  Clark  treats  by  means  of  warm  baths, 
the  oiled-silk  jacket,  and  those  medicines  which  produce  free 
diaphoresis. 

GANGRENE   OF   THE   LUNGS. 

Dr.  Clark's  treatment  of  gangrene  of  the  lungs  is  altogether 
sustaining,  consisting  of  sustaining  foods  and  sustaining  medi- 
cines. The  alcoholics  are  administered  carefully,  according 
to  the  state  of  the  pulse.  Quinia  is  given  in  8  or  10-grain 
doses,  thrice  daily. 

MULTIPLE   ABSCESS   OP  THE   LUNGS. 

The  treatment  pursued  is  sustaining  all  the  way  through, 
and,  as  there  is  certain  to  be  hectic  fever,  Dr.  Clark  has  found 
quinia  to  be  of  the  greatest  service. 

CHRONIC   PNEUMONIA. 

The  treatment  here,  again,  is  sustaining  to  a  high  degree. 
Counter-irritation  is  produced  by  means  of  iodine  applied  to 
the  affected  side  of  the  chest.  Some  three  or  four  spots  are 
chosen,  and  each  spot  is  painted  about  three  times  a  day. 
The  patient  is,  at  the  same  time,  encouraged  to  eat  all  the 


14  Notes  of  Hospital  Practice. 

food  he  can  digest.    Tonics  are  the  medicines  upon  which  Dr 
Clark  places  chief  reliance. 


THE   RHEUMATISM   OP  PHTHISIS. 

The  Roosevelt  patients  are  placed  upon  : 

K     Potassii  iodid 3J. 

Fl.  ex.  conii giij. 

Tr.  opii  camph f^  ij. 

Aq.  aurant.  flor f^iv. 

Aquse f 3  iv.  M. 

SIG. — A  teaspoonful  thrice  daily. 

HAEMOPTYSIS 

Has  been  arrested  at  the  Roosevelt  Hospital  by  gtt.  xl  of  fl. 
ex.  ergot,  taken  every  three  hours. 

ACUTE   DYSENTERY. 

The  first  indication,  according  to  Dr.  Austin  Flint,  consists 
in  a  complete  evacuation  of  the  bowels,  provided  that  this 
effect  has  not  already  been  accomplished  by  a  spontaneous 
prodromic  diarrhoea.  Castor  oil  is  the  remedy  which  he  gen- 
erally employs  to  meet  this  indication.  He  sometimes,  how- 
ever, prescribes  salines.  Then  the  inflamed  intestines  are  kept 
perfectly  quiet  by  the  use  of  opium.  Of  the  three  different 
modes  of  administering  opium  he  prefers  that  by  enema. 
When  the  alimentary  canal  becomes  again  more  or  less  loaded, 
the  oil  or  salines  are  repeated. 

In  a  certain  number  of  cases  he  has  employed  the  new  treat- 
ment by  ipecac,  administering  from  25  to  30  grains  of  the 
powder  every  eight  or  ten  hours. 

The  diet  employed  consists  in  those  articles  of  food  which 
are  as  completely  digestible  as  possible.  The  tenesmus  is 


General  Diseases.  15 

relieved  by  cold  water  and  ice  applied  to  the  rectum,  or  by 
warm,  soothing  applications  over  the  abdomen. 


EPIDEMIC   DYSENTERY. 

Purgatives  are  here  avoided.  The  chief  reliance  is  placed 
upon  opium.  It  is  administered  early  and  persistently,  and 
to  the  extent  of  absolutely  quieting  the  intestines,  but  at  the 
.same  time  avoiding  the  risk  of  narcotism.  Astringents  are 
administered  when  they  are  well  tolerated  by  the  stomach,  but 
they  are  never  allowed  to  take  the  place  of  the  opium.  Alco- 
hol is  given  in  large  quantities.  In  a  word,  the  persistent  use 
of  alcohol  and  opium  is  regarded  by  Dr.  Flint  as  the  most 
essential  feature  of  the  treatment  of  epidemic  dysentery. 

CHRONIC   DYSENTERY. 

Dr.  Flint  places  more  confidence  in  bismuth,  given  in  large 
and  regular  doses,  than  in  either  the  nitrate  of  silver  OB  sul- 
phate of  copper.  He  rarely  gives  less  than  3  j.  His  usual 
dose  is  from  3  ss  to  3  ij.  His  patients  are  sustained,  by  tonic 
remedies  and  a  nutritious  diet.  A  change  of  climate  he  regards 
as  a  most  important  element  in  the  management  of  the  disease. 
A  uniformly  cold  and  dry  atmosphere  has  been  found  by  him 
to  be  that  best  suited  to  these  cases. 

SUBACUTE   ENTERITIS. 

The  intestines  are  emptied  by  a  purgative  and  then  kept 
quiet  by  moderate  doses  of  opium.  Dr.  Flint  sees  that  the 
diet  is  carefully  regulated. 

CHRONIC   DIARRHfEA    IN   ADULTS. 

If  the  lesion  is  situated:  in  the  large  intestine,  and  the  irri- 
tability of  the  large  intestine,  is  kept  up  by  the  presence  of 


16  Notes  of  Hospital  Practice. 

food  in  the  stomach,  the  treatment  pursued  at  Bellevue  Hos- 
pital consists  in  not  irritating  the  stomach,  and  in  thereby 
avoiding  the  exciting  cause  of  the  discharges.  With  this  ob- 
ject in  view,  the  patient  is  put  upon  a  milk  diet.  In  most 
cases,  the  milk  does  not  irritate  the  stomach.  A  certain  por- 
tion of  the  casein  is  digested  in  the  stomach,  and  the  remain- 
der is  digested  in  the  small  intestine.  Again,  as  the  result  of 
experience,  it  is  known  that  chronic  inflammation  of  the  upper 
part  of  the  large  intestine  is  frequently  best  treated  by  rest, 
and  a  diet  consisting  principally  of  fat,  in  the  form  of  either 
cream  or  cod-liver  oil.  By  placing  a  patient  on  a  milk  diet, 
both  indications  are  fulfilled.  The  real  difficulty  encountered 
in  treating  such  cases  is  to  change  from  the  milk  to  some  other 
diet,  when  a  change  became  desirable  or  necessary.  While 
they  adhere  rigidly  to  a  milk  diet,  it  is  cured;  but  as  soon  as 
they  return  to  ordinary  food,  the  diarrhoaa  returns. 

If  complete  control  can  be  had  of  a  patient,  permanent  cure 
can  be  accomplished  in  many  cases  by  introducing  the  ordi^ 
nary  diet  very  gradually.  First,  stopping  the  milk  entirely, 
not  continuing  it  with  other  articles  of  food.  Then  very  care- 
fully regulating  the  quantity  and  quality  of  the  food  which  the 
patient  is  to  take.  The  first  article  used  to  the  best  advantage 
is  meat — beef  or  mutton — finely  cut  and  taken  in  small  quan- 
tities at  a  time ;  and  to  this,  perhaps,  a  small  quantity  of  toast 
and  tea,  or  an  egg,  is  added  three  times  a  day.  After  a  few 
days,  perhaps,  rice  is  added;  and  so,  adding  the  most  easily 
digested  articles,  the  patient  is  gradually  changed  from  one 
diet  to  another.  If  the  diarrhrea  returns,  the  patient  is  at 
once  put  back  on  a  milk  diet.  The  gradual  transfer  to  the 
ordinary  diet  is  sometimes  aided  by  certain  drugs.  The  min- 
eral acids  and  preparations  containing  strychnia  have  been 
found  to  be  the  best  that  can  be  employed,  taken  with  the 
meals.  The  following  is  often  used  : 

R     Tr.  nucis  vom gtt.  xx. 

Acid,  nitro-muriatic.  dil.... gtt.  xx.         M. 

SlG.— Dilute  well  with  water,  and  take  three  times  a  day,  with  mea^t; 


General  Diseases.  17 

In  this  way  these  cases  are  not  only  temporarily,  but  per- 
manently cured. 

THE   INTRAVENOUS   INJECTION   OF   AMMONIA. 

Dr.  Gaspur  Griswold  claims  that  the  intravenous  injection 
of  ammonia  is  a  prompt  and  powerful  means  of  stimulation, 
acting  efficiently  in  cases  where  other  measures  are  of  no  avail, 
and  that  no  bad  effects  follow  its  employment.  He  employs, 
for  this  purpose,  a  solution  of  aqua  ammonia  (equal  parts  of 
aqua-ammonia  and  water.)  He  does  not  perform  intravenous 
injection  through  the  skin,  but,  dissecting  down  upon  the  vein 
and  exposing  it,  he  then  introduces  the  needle  until  the  point 
is  felt  free  in  the  interior  of  the  vessel. 


OPHTHALMIA   NEONATORUM. 

Dr.  Knapp  does  not  think  it  necessary  to  apply  any  caustic, 
If  any  is  employed,  he  never  uses  a  stronger  solution  of  the 
nitrate  of  silver  than  3  grains  to  the  ounce.  He  believes  in 
the  great  importance  of  cold  applications.  These  application? 
are  made  night  and  day,  and  great  care  is  taken  to  open  the 
eyelids  and  carefully  wash  away  the  secretions..  This  is  done 
every  half  hour.  When  there  is  proliferation  of  the  mucous 
membrane,  the  nitrate  of  silver  is  the  proper  remedy. 

ACUTE   PRIMARY   OTORRHO3A. 

Dr.  H.  Knapp  lays  great  stress  upon  the  necessity  for  rest, 
in  the  treatment  of  this  disease.  His  local  treatment  consists 
in  injections  of  warm  water  into  the  ear;  leeches  behind  the 
ear;  inflation  of  the  drum — at  first,  cautiously,  through  the 
catheter,  then  according  to  Politzer's  method ;  astringent  gar- 
gles; steaming  of  the  ear;  paracentesis  of  the  drum;  opening 
of  the  mastoid  process;  cleansing  of  the  ear  by  syringing  and 
wiping  with  u  dentist's  cotton-holder;  the  use  of  astringent 


18  Notes  of  Hospital  Practice. 

injections  into  the  ear,  suited,  in  strength,  to  the  copiousness 
of  the  discharge  and  the  proliferation  of  the  mucous  mem- 
brane. 


RECTAL   ALIMENTATION. 

Dr.  A.  H.  Smith  reaches  the  following  conclusions: 

1.  That  defibrinated  blood  is  admirably  adapted  to  sustain- 
ing nutrition  by  rectal  alimentation. 

2.  That  from  1  to  6  ounces  can  be  retained,  and  that  fre- 
quently a  larger  quantity  can  be  used  without  very  much  trace 
of  blood  in  the  fascal  evacuations. 

3.  That  in  about  one-third  of  the  cases,  it  produces  more  or 
less  constipation. 

4.  That  in  a  small  proportion  of  cases,  constipation  persists 
and  necessitates  the  discontinuance  of  the  blood. 

5.  That  in  a  small  percentage  of  cases,  irritability  of  the 
bowels  attends  its  protracted  use. 

6.  That  it  is  only  an  aid  to  stomach  alimentatio'n. 

7.  That  its  use  is  indicated  in  cases  in  which  asthenia  is 
developed  by  disease  not  involving  the  large  intestines. 

8.  That  in  unfavorable  cases  it  is  capable  of  giving  a  favor- 
able impulse  to  nutrition  not  obtainable  from  other  sources. 

9.  That  its  use  is  entirely  unattended  by  danger. 

MITRAL   AND   AORTIC   REGURGITATION. 

Dr.  Alfred  Loomis  gets  rid  of  the  pulmonary  congestion 
by  the  application  of  dry  cups.  To  improve  the  nutrition 
and  stimulate  the  flagging  heart  he  gives  iron  and  digitalis  in 
combination.  Digitalin  he  sometimes  finds  to  be  the  more 
efficient  preparation  of  the  latter  drug.  The  dose  is  from 
VlOO  to  1/60  °f  a  grain  twice  daily.  Absolute  freedom  from 
mental  excitement  and  from  over-exertion  is  insisted  upon. 
The  diet  allowed  is  principally  albuminous.  All  stimulus  is 
avoided.  To  relieve  the  portal  circulation  an  occasional 


General  Diseases.  19 

drastic  purge  is  given — calomel  being  the  drug  generally  em- 
ployed. 

MORPHIA   VOMITING — OPIUM    POISONINO. 

Dr.  Montrose  A.  Fallen  has  derived  very  excellent  results 
from  the  hypodermic  injection  of  from  30  to  40  minims  of  the 
fluid  extract  of  coffee  into  the  epigastrium. 


ACCUMULATIONS   IN   THE   EABS. 

Dr.  Samuel  Sexton  has  found  syringing  with  a  suitable  in- 
strument to  be  the  best  means  for  removing  these  accumula- 
tions, but  he  thinks  that  in  cautious  hands  the  curette  and 
forceps  are  often  of  service.  The  water  used  in  the  syringe 
is  as  warm  as  the  patient  can  bear.  The  syringe,  when  filled, 
is  held  in  the  right  hand,  while  the  operator  pulls  the  auricle 
upward,  backward  and  outward  with  the  left  hand,  thus  freely 
exposing  the  opening  of  the  meatus.  When  through  syring- 
ing, the  meatus  is  dried  with  absorbent  cotton  and  a  firm 
pledget  of  wool  is  worn  in  the  ear  for  a  time. 

EMESIS. 

Excellent  results  have  been  obtained  at  the  Presbyterian 
Hospital,  from  the  employment  of  faradization  in  these  cases, 
one  electrode  being  placed  in  the  right  auriculo-maxillary 
fossa,  and  the  other  being  rubbed  over  the  stomach  for  several 
minutes. 

ACUTE    RHEUMATISM. 

Dr.  Wrn.  H.  Thomson  uses  this  prescription: 

R     Sol.  acid,  salicyl.  (gr.xl-fgj) f^  q. 

Tinct.  gaultherise f^j. 

Aquse fjiv.  M. 

Sio. — A  tablespoonful. 


20  Notes  of  Hospital  Practice. 

CIRRHOSIS  OF  THE  LIVER. 

Dr.  Thomson  orders  gr.  xx  of  the  iodide  of  potassium  thrice 
daily  and  half  of  the  following  mixture  in  the  morning : 

R     Magnes.  sulph gss. 

Ferri  sulph gr.  viii. 

Acid,  sulph.  dil f^j. 

Aquae.... q.  s.  ad  f%  iv.  M. 

In  some  cases  a  pill  with  the  following  constituents  has  had 
good  effects. 

R     Belladon gr.  vj. 

Ex.  nuc.  vom g.  jss. 

Ex.  colocynth gr.  xij. 

Aloes  Socot gr.  vj.  M. 

Et.  in  pil.,  No.  vj.  div. 
Sio. — One  thrice  daily. 

URJEMIA. 

Jaborandi  has  been  found  at  Bellevue  Hospital  to  be  a  very 
effective  substitute  for  the  old  hot-air  bath,  acting  more  quickly 
and  surely.  It  is  given  hypodermically  in  the  shape  of  drachm 
doses  of  the  fluid  extract.  This  dose  is  repeated  every  other 
day. 

CHRONIC   NEPRHITIS. 

Cases  of  this  disease  have  been  treated  very  successfully  at 
Bellevue  Hospital  with  jaborandi.  The  dose  is  a  drachm  of 
the  fluid  extract  given  every  other  morning,  the  patient  being 
kept  in  bed  until  dinner-time,  when  the  sweating  is  over.  It- 
has  been  found  better  not  to  give  it  at  night,  as  the  bed  clothes 
become  saturated  with  perspiration  and  sleep  is  disturbed  and 
uncomfortable. 

BRONCHO-PNEUMONIA. 

Dr.  Wm.  H.  Thomson  puts  his  patients  upon  a  milk  diet, 


General  Diseases.  21 

with  an  allowance  of  f  f  iij  of  whiskey  a  day,  and  prescribes 
the  following: 

R      Ammon.  carb.... gr.  Ixxx. 

Mucilag., 

Aquae . ... ia  fgj.  M. 

SIG. — A  tablespoonful  thrice  daily. 

This  mixture  is  alternated  with  one  containing  compound 
*yrup  of  squill,  wine  of  ipecacuhana,  and  sulphate  of  morphia. 


ACNE  BOSACEA. 

The  pustules  are  all  opened  by  means  of  a  wide  and  reason- 
ably deep  incision.  The  papules  are  then  treated  in  the  same 
manner,  being  cut  until  they  bleed  quite  freely.  Among  the 
methods  of  removing  the  congestion,  recommended  by  Dr.  H. 
G.  Piffard,  are  (1)  poulticing;  (2)  holding  the  face  in  hot 
water — [this  is  accomplished  as  follows;  The  patient  takes  a 
basin  of  hot  water,  immerses  his  face,  withdraws  it  and 
breathes,  then  immerses  it  again,  and  so  on] — (3)  covering  the 
face  with  pieces  of  muslin  kept  constantly  wet  with  water  as 
hot  as  can  be  borne.  If  there  is  much  congestion  of  the  skin, 
where  it  is  not  invaded  by  the  pustules  and  papules,  little 
scarififtitions  are  made  wherever  it  is  most  marked.  Infiltra- 
tion is  reduced  by  the  use  of  alkaline  applications.  The  face 
is  thoroughly  rubbed  three  or  four  times  a  week  with  green 
soap.  The  red  color  and  polished  appearance  of  the  skin  fol- 
lowing the  use  of  the  soap  is  most  readily  removed  by  the 
use  of  sulphur. 

The  following  is  the  combination  employed : 

R     Lae.  sulphw, 
Glycerine, 
Rose  water, 
Bay  rum , la  q.  s. 

When  varicose  veins  are  present,  they  are  -destroyed  either 


22  Notes  of  Hospital  Practice. 

by  dividing  them  crosswise,  or,  still  better,  by  dividing  them 
lengthwise,  throughout  their  entire  extent,  with  a  thin,  sharp 
knife,  and  then  rubbing  a  small  amount  of  the  persulphate  of 
iron  into  them.  In  some  cases,  they  are  obliterated  by  means 
of  a  white-hot  needle.  The  marked  hypertrophy  of  the  skin 
present  later  on  in  the  course  of  the  disease,  is  treated  by  the 
constant  galvanic  current,  applied  directly  through  the  nose. 
When  the  thickening  is  excessive,  the  use  of  red-hot  needles, 
or  the  excision  of  portions  of  the  integument,  becomes  neces- 
sary. 

CROUPOUS   PHARYNGITIS. 

Dr.  Thomson  prescribes  a  milk  diet  and  f§iv  of  whiskey 
a  day,  with  the  following  as  a  gargle  : 


R     Sol.  brominii,  (^j-f^ij) 
Glycerinse 
Aquse  ..............................................  q.  s.  ad  f^  iv.  M. 


.         TYPHOID   FEVER. 

Dr.  Alonzo  Clark  believes  that  a  case  of  typhoid  fever,  of 
average  severity,  needs  no  medication  except  for  the  relief  of 
symptoms. 

Diarrhoea  he  manages  by  the  following : 

R     Bismuth,  subnit /. 3J. 

Morphise  sulph gr- j-  M- 

Et  in  chart.  No.  xii  div. 
Sio. — One  to  four  a  day. 

Other  astringents  which  he  has  found  to  be  of  service  are 
tr.  kino,  tr.  catechu,  and  decoction  of  blackberry  root. 

Cough,  when  it  is  the  result  of  a  catarrh,  is  treated  either 
by  the  comp.  tr.  of  benzoin,  in  10-drop  doses  every  three  or 
hours,  or  by  means  of  the  following  combination ; 


General  Diseases.  23 

ft     Mist,  guaici f  3  j~f3  ^ 

Tr.  balsam,  tolu gtt.  vj-x.      M. 

Sio. — Every  two  to  four  hours. 

Occasionally,  good  has  been  accomplished  by  the  inhalation 
of  the  vapor  of  warm  water  for  an  hour  or  two  every  day. 

Restlessness  is  soothed  by  sponging  the  surface  of  the  oody 
with  warm  or  cold  water.  In  some  cases,  a  Dover's  powder 
is  required. 

When  the  temperature  of  the  body  runs  very  high,  quinia  is 
given  in  decided  doses,  or  coid  water  is  employed.  In  young 
persons,  Dr.  Clark  finds  the  cold  bath  the  most  convenient 
and  efficient  means  of  reducing  temperature.  The  tempera- 
ture of  the  bath  used  is  just  10°  below  the  temperature  of 
the  patient's  body.  The  patient  is  allowed  to  remain  in  the 
bath  for  20  minutes.  If  the  temperature  rises  again,  another 
bath  is  given. 

Hemorrhage  from  the  bowels  is  controlled,  if  possible,  by 
absolute  rest  and  doses  of  the  fluid  extract  of  ergot. 

In  perforation  of  the  bowels,  the  patient  is  placed  thoroughly 
under  the  influence  of  opium. 

Regarding  diet,  Dr.  Clark  believes  in  the  steady  and  perse- 
vering administration  of  such  food  as  can  be  absorbed  by  the 
stomach.  Milk,  beef  tea,  raw  eggs  beaten  up  with  water  and 
made  of  such  consistency  that  they  can  be  eaten  with  a  spoon, 
and  expressed  beef-juice,  are  all  of  value.  Where  one  disa- 
grees, another  is  substituted.  The  expressed  juice  of  beef  is 
obtained  by  cooking  a  piece  of  steak  so  as  just  to  crust  the 
surfaces,  and  then  squeezing  out  the  juice  with  a  lemon- 
squeezer.  As  the  disease  advances,  the  food  administered  is 
more  and  more  sustaining.  When  the  stomach  fails  to  retain 
(bod,  nutritious  enemata  are  employed. 

Dr.  Clark  considers  plenty  of  fresh  air  as  of  prime  import- 
ance to  typhoid  fever  patients.  He  always  insists  that  a  wiu- 
dow  on  the  side  of  the  room  opposite  the  patient,  be  dropped 
a  certain  distance  from  the  top,  even  in  the  winter  season,  and 


24  Notes  of  Hospital  Practice. 

that  the  patient  is  protected  from  the  draft  by  the  use  of  a 
screen. 

Bed  Sores.  Nothing  has  been  found  so  effectual  for  their 
prevention  and  treatment  as  a  water-bed.  Where  this  cannot 
ta  obtained,  the  best  substitute  is  the  padded  ring,  or  a  rubber 
ring  filled  with  air. 

Tympanites.  Cold  compresses  are  applied  to  the  abdomen, 
and  covered  with  oiled  silk.  Where  this  fails,  a  stimulating 
injection  is  given,  consisting  of  Oss  of  a  solution  composed 
of  Labarraque's  solution,  1  part,  and  water,  16  parts.  In 
other  cases,  from  8  to  10  drops  of  the  spirits  of  turpentine 
are  given  in  mucilage. 

Abscesses  are  always  opened  early.  . 

Peri-par otiditis  is  subdued  by  cold  compresses  or  ice,  locally. 

The  alvine  discharges  of  Dr.  Clark's  patients  are  always 
disinfected  at  once.  The  way  in  which  this  is  done  is  by 
placing  in  the  bed-pan  or  vessel  a  half  pint  or  a  pint  of  a 
solution  of  the  sulphate  of  iron,  just  before  it  is  to  be  used. 

The  bed-clothes,  as  soon  as  they  are  soiled,  are  removed  from 
the  bed  and  plunged  into  a  tub  of  water,  which  is  sufficiently 
impregnated  with  carbolic  acid  to  secure  effectual  disinfection. 

Dr.  Clark  is  in  the  habit  of  administering  some  mineral 
acid  in  all  cases  of  typhoid  fever — hydrochloric  is  that  gen- 
erally employed — but  does  not  think  much  of  the  German 
treatment  by  iodine  or  calomel. 

Two-thirds  of  his  patients  have  been  found  to  do  better 
without  stimulants  than  with  them.  A  good  general  rule  is 
the  following:  When  alcoholics  diminish  the  frequency  and 
increase  the  force  of  the  pulse,  they  do  good.  In  such  cases, 
tiiey  are  given  in  a  quantity  sufficient  to  increase  the  force  of 
the  pulse,  and  to  diminish  the  restlessness  and  suffering  of  the 
patient. 

Within  the  last  two  or  three  years,  the  only  precaution 
taken  against  contagion,  at  Bellevue  Hospital,  has  been  to  dis- 
infect the  stools.  This  is  done,  generally,  with  sulphate  of 
iron,  which  is  placed  in  the  bed-pan  previous  to  its  being  used, 


General  Diseases.  25 

Commercial  muriatic  acid,  diluted,  is  poured  into  the  pan  after 
the  passage.  The  stools  being  disinfected,  no  further  attempts 
at  protecting  the  house-staff,  nurses,  or  other  patients,  are 
employed. 

The  treatment  at  present  in  vogue  is  that  of  quinine  and 
baths.  This  was  begun  four  or  five  years  ago,  and  has  received 
such  favor  that  it  is  quite  the  routine  now.  The  quinine  is 
given  differently.  Perhaps  the  most  popular  way  Has  been 
10  grains,  two  or  three  times  a  day,  the  evening  dose  being 
doubled,  if  the  temperature  rises  above  a  particular  height, 
say  105°.  It  sometimes  causes  gastric  irritation,  being  given 
in  powder  form.  If  it  is  vomited,  pills  are  tried,  and  finally, 
double  doses  by  rectum.  Quinidia  was  used  for  a  short  time, 
and  it  reduced  temperature  like  quinine,  but  irritated  the 
stomach  more.  Baths,  in  every  shape,  are  used,  but  the 
sponge-bath  is  the  form  most  adopted.  The  patient's  tem- 
perature is  taken ;  if  found  above  a  certain  height,  he  is 
stripped  either  entirely  naked,  or  perhaps  only  the  upper  half 
of  the  body.  He  is  then  sponged  over  with  water,  at  a  tem- 
perature .of  from  60°  to  80°.  If  only  half  the  body  is 
uncovered  at  a  time,  that  part  is  allowed  to  dry,  and  it  is  then 
covered,  and  the  rest  of  the  surface  sponged.  This  process  is 
kept  up  for  15  minutes.  If  that  is  insufficient  to  reduce  the 
temperature,  it  is  prolonged  to  half  an  hour.  It  is  repeated 
every  one,  two,  or  three  hours,  according  to  the  result  obtained. 
At  the  end  of  the  bath,  a  little  whiskey  is  generally  given. 

The  effect  of  the  quinine  on  the  temperature  is  to  reduce 
it  slightly  in  a  considerable  number  of  cases.  Its  effect  on 
the  patient  is  to  produce  nausea  and  vomiting  in  a  small 
number  of  cases. 

The  sponge-baths  are  almost  always  pleasant  to  the  patient, 
if  not  too  frequently  repeated.  If  given  every  hour,  or  two 
hours  even,  they  seem  to  weary  and  annoy  him.  They  cer- 
tainly reduce  the  temperature  in  most  of  the  cases.  In  a 
small  number  of  these  the  reduction  seems  to  last  for  many 
hours.  Sometimes,  two  or  three  baths  given  in  the  afternoon 


26  Notes  of  Hospital  Practice. 

and  evening  reduce  the  fever  two  or  three  degrees,  and  it 
keeps  down  for  twelve  hours.  But  it  is  not  very  rare  that 
the  baths  are  given  every  hour  even,  without  producing  very 
marked  effect.  The  sponge-bath  is  a  much  more  efficient  an- 
tipyretic than  quinine.  The  wet  pack  is  hardly  used  now. 
In  one  case  where  it  was  employed,  pneumonia  complicated 
the  disease.  The  plan  of  placing  the  patient  in  water  at  a 
temperature  of  98°,  and  then  gradually  lowering  it,  has  been 
tried  a  number  of  times,  and  so  far  no  deaths  can  be  be  traced 
to  it.  But  these  gradually-cooled  baths  are  uniformly  annoy- 
ing and  depressing  to  the  patients.  They  don't  like  them. 
Neither  have  they  been  proved  to  reduce  temperature  perma- 
nently any  better  than  the  sponge-baths  do. 

Several  cases  have  been  treated  upon  the  Kibbe  bed.  Its 
action  and  effectiveness  were  similar  to  immersion  in  the  bath- 
tub. It  did  not  eliminate  the  fever  from  the  disease. 

The  results  of  the  treatment  of  typhoid  fever  patients  at  Belle- 
vue  Hospital,  within  the  past  ten  years,  has  shown  that  large 
doses  of  quinia,  and  that  the  antipyretic  treatment  by  cold  baths 
are  unnecessary,  and  that  the  employment  of  mineral  acids  and 
of  symptomatic  remedies  is  sufficient. 

Dr.  Alfred  Loomis  does  not  believe  in  the  efficacy  of  cold 
baths  or  of  large  doses  of  quinia  in  arresting  the  development 
of  typhoid  fever.  He  maintains  the  temperature  of  the  room 
iu  which  the  patient  lies  below  60°F.  Frequent  sponging  of 
the  body  with  cold  water  has  been  of  service  in  his  hands.  As 
soon  as  the  axillary  temperature  in  the  evening  rises  above 
103°F.  he  places  his  patients  in  a  bath  of  a  temperature  of 
from  70°-80°F.,  and  then  gradually  lowers  that  temperature 
until  the  patient's  temperature  begins  to  fall.  When  the 
patient's  temperature  reaches  103°  he  is  to  be  taken  out  and 
pat  to  bed.  When  his  patients  are  too  weak  to  be  put  in  the 
bath  he  employs  the  wet  pack.  He  regards  cold  baths  as  con- 
tra-indicated by  feebleness  of  the  heart's  action. 

As  an  antipyretic  he  gives  gr.  xxx  of  quinia  in  one  dose,  01 
gr.  x  every  half-hour  until  gr.  xxx  or  xl  have  been  adminis- 


General  Diseases.  27 

tered.     He  is  in  the  habit  of  administering  an  antipyretic  dose 
of  quinia  when  the  temperature  has  been  reduced  by  the  baths. 
He  lays  down  the  following  rules  with  regard  to  the  use  of 
stimulants. 

1.  They  are  never  to  be  administered  indiscriminately — that 
is,  they  are  never  to  be  given  simply  because  a  patient  has 
typhoid  fever. 

2.  When  there  is  a  reasonable  doubt  as  to  the  propriety  of 
giving  or  withholding  stimulants,  it  is  safer  to  withhold  them, 
at  least  until  the  signs  which  indicate  their  use  become  more 
marked. 

3.  In  giving  stimulants  the  effects  of  the  first  few  doses  are 
to  be  very  carefully  watched. 

4.  Stimulants  are  contra-indicated  by  dry  tongue,  restless- 
ness, increasing  delirium,  pulse  and  temperature. 

As  diet  he  allows  at  first  only  milk  diluted  with  lime-water 
and  later,  cream  and  the  yolk  of  eggs  in  milk. 

Diarrhoea  as  occurring  early  in  the  course  of  the  disease  he 
allows  to  go  untreated.  When  it  comes  011  in  the  third  or 
fourth  week  he  controls  it  by  means  of  opium. 

Tympanitis  he  relieves  by  the  application  of  turpentine  stupes 
to  the  abdomen. 

Hemorrhage  is  treated  by  absolute  rest,  opium,  internally, 
and  ice  bags  applied  over  the  abdomen. 

Bronchitis  he  has  found  amenable  to  dry  cupping  and  the 
internal  administration  of  the  carbonate  of  ammonium. 

Laryngitis.  A  small  blister  is  applied  on  either  side  of  the 
angle  of  the  jaw  and  the  whole  neck  enveloped  in  a  poultice. 

Bed-sores  are  prevented  by  frequently  bathing  the  parts 
with  camphor.  If  the  sores  penetrate  the  integument  they 
are  washed  with  a  weak  solution  of  carbolic  acid  and  after- 
wards covered  with  lint  smeared  over  with  vaseline. 

Headache.  Warm  fomentations  are  applied  to  the  forehead, 
^rfnong  the  anodynes  the  best  for  the  treatment  of  this  symp- 
tom are  the  bromides  and  chloral. 


28  Notes  of  Hospital  Practice. 

Delirium  is  generally  relieved  by  chloral  and  opium.  In 
some  cases  the  best  results  follow  the  use  of  stimulants. 

Daring  convalescence  Dr.  Loomis  regulates  the  patient's 
diet  with  the  utmost  care,  allowing  no  indigestible  article  of 
food. 

ACUTE    TRACOMA. 

Cleansing  and  the  use  of  cold  are  regarded  by  Dr.  Knapp 
as  the  proper  methods  of  treatment.  He  rarely  resorts  to  divi- 
sion of  the  outer  commissure.  He  believes  that  slitting  of  the 
cornea  is  done  too  frequently.  He  employs  eserine  to  reduce 
tension.  The  solution  of  the  drug  used  contains  gr.  iv  of 
eserine  to  the  f  f  j  of  water. 


LARYNGEAL   PHTHISIS. 

Dr.  F.  H.  Bos  worth  first  cleanses  the  parts  by  means  of 
one  of  these  solutions  : 


(1.)  R     Acid,  carbol.  cryst 
Sodae  bicarb., 
Sodse  biborat  ..........................................  aa  gr.  xxiv. 

Glycerinse  ..................................................  f£  jss. 

Aquae  rosae  .....................................  q.  s.  ad.  f£  viij.         M. 

(2.)  R     Sodae  salicylat  .............................................  gr.  x. 

Sodse  biborat  ...............  .  ..............................  9j. 

Glycerinae  ..................................................  f.^j. 

Aquas  rosae  .....................................  q.  8.  ad.  £3;  viij.         M. 

Whichever  of  these  is  employed  is  best  administered  by 
means  of  the  Sass  spray  tubes  with  the  compressed  air  appa- 
ratus, at  a  pressure  of  from  15  to  20  pounds.  The  tongue  is 
protruded  and  held,  thus  lifting  the  epiglottis  and  uncovering 
the  laryngeal  cavity  —  the  patient  being  directed  to  sound  in 
high  key  A  —  the  point  of  the  tube  is  then  passed  beyond  tUu 
crest,  and,  the  pressure  being  turned  on,  the  cavity  is  flooded 
with  the  spray.  This  is  repeated  several  times  until  the  parts 


General  Diseases.  2V 

are  thoroughly  cleansed.  If  the  application  causes  pain  a  5- 
10  gr.  solution  of  morphia,  rendered  alkaline  by  the  addition 
of  sodii  carb.  or  potassii  carb.,  is  used. 

As  astringents  Dr.  Bosworth  employs  gr.  x  solutions  of  th'- 
sulphate  of  zinc;  or  argenti  nitrat.,  gr.  iij-v  to  f  fj ;  or  ziuci' 
chloridi,  gr.  iij  to  f  |j  ;  or  tannin,  et  glycerine,  f  3j  to  f  |j  ;  m 
liq.  ferri  persulph.,  Hfl,xx  to  f  1  j. 

After  applying  some  astringent,  iodoform  is  used,  in  i<u 
following  shape : 

R     Morphise ,. gr.  x. 

Tannin  55  ij. 

lodoform. 3 vj.  M. 

Et  ft.  in  pulv. 

Or  else  he  employs  the  saturated  solution  in  ether  (7fl  xl 
f  §  j.)  The  powder  is  applied  by  means  of  the  powder-blower. 
This  instrument  was  devised  by  Dr.  Andrew  H.  Smith,  of 
New  York,  and  consists  of  a  small,  open-mouthed  bottle, 
through  the  cork  of  which  two  tubes  are  passed,  bent  at  right 
angles;  to  one  tube  is  attached  a  single  hand-ball ;  the  other 
is  fashioned  to  adapt  it  for  the  special  application  to  be  made. 
The  powder  being  placed  in  the  bottle,  a  single  quick  pressure 
on  the  hand-ball  drives  a  current  of  air  into  the  bottle,  which 
stirs  the  powder  up  into  a  fine  cloud,  and  drives  it  out,  in  this 
state  of  fine  diffusion,  through  the  other  tube,  and  deposits  it, 
in  an  evenly- distributed,  thin  layer,  over  the  parts  which  are 
to  be  medicated.  Dr.  Bosworth  does  not  believe  in  the  use 
of  the  brush,  sponge,  or  probe,  as  media  of  medication  in  this 
disease,  but  regards  them  as  calculated  to  injure  the  diseased 
parts.  He  always  uses  the  spray,  or  insufflator.  He  does 
not  think  much  of  the  atomizer.  He  thinks  the  operation  of 
tracheotomy  a  simple  one,  and  one  which  might  be  performed 
much  more  frequently  than  it  is,  so  giving  the  larynx  rest. 

NASO-PHARYNGEAL   CATARRH. 

Cleanliness  is  regarded  as  the  chief  requisite  by  Dr.  \V.  F. 


30  Notes  of  Hospital  Practice. 

Duncan.  The  diseased  mucous  membrane  is  always  cleansed 
before  medicines  are  applied.  The  following  alkaline  and 
disinfecting  solution  has  been  found  to  be  of  service : 

R     Acid,  carbol. ' 3jss. 

Sodii  bibor., 

Sodii  bicarb aa  £;ij. 

Glycerinse f^  ij. 

Aquae q.  s.  ad  iOij.  M. 

This  is  used  in  the  atomizer,  the  post-nasal  syringe,  or  the 
douche.  The  best  method,  in  Dr.  Duncan's  opinion,  is  that 
by  the  post-nasal  syringe.  It  is  entered  flat  on  the  tongue, 
which  is  depressed  by  its  nozzle;  its  point  is  then  quickly 
introduced  behind  the  palate,  and  the  contents  suddenly  and 
forcibly  ejected  by  driving  home  the  piston.  The  hand-ball 
atomizer,  when  used  with  about  30  pounds  pressure,  has  been 
found  to  be  very  efficient  in  dislodging  mucus  from  the  supe- 
rior meatus.  It  is  better  for  children  than  the  post-pharyn- 
geal  syringe. 

Medicines  are  applied  in  the  form  of  spray,  powder,  or 
solution.  The  spray  is  regarded  as  the  best  medium.  As  an 
efficient  astringent,  Dr.  Duncan  employs  gr.  xv  of  the  sulphate 
of  zinc  to  the  f  ij  of  water.  If  the  case  is  a  mild  one,  a 
solution  is  not  more  than  one-fifth  this  strength.  Applica- 
tions are  made  three  times  a  week,  and  in  the  intervals,  the 
patient  applies  the  cleansing  solution  above  given,  himself,  by 
means  of  Delano's  atomizer,  or  the  post-pharyngeal  douche. 
When  there  is  excess  of  secretion,  and  but  little  sensibility, 
ferric  alum  (gr.  v-xx  to  aqua  f  3  j)  has  been  found  to  be  useful. 
His  general  rule  is  to  ring  the  changes  on  astringents  until  a 
good  one  has  been  found.  Others  than  those  already  men- 
tioned, which  he  employs,  are  chlorate  of  potassium,  nitrate 
of  silver,  tannin,  and  chloride  of  zinc.  When  pain  follows 
the  use  of  an  astringent,  a  spray  of  morphia  is  employed. 
When  stronger  applications  are  needed,  caustics  are  applied 
with  a  probe,  one  end  of  which  is  tightly  wrapped  with 
cotton. 


General  Diseases.  31 

The  probe  employed  has  a  short  arm  of  an  inch  in  length, 
so  that  applications  can  be  made  with  it  behind  the  palate  to 
the  vault.  Hypertrophied  tissue  is  always  destroyed  by 
means  of  forceps,  knife,  or  galvano-cautery.  Polyphoid  thick- 
ening of  the  ends  of  the  turbinated  bones  is  touched  with 
caustic  applied  by  means  of  a  probe  passed  through  a  shield. 
Where  there  is  adenoid  degeneration  the  vault  is  curetted. 

In  the.atrophic  form  of  naso-pharyngeal  catarrh,  stimula- 
ting solutions  are  employed  by  means  of  the  spray,  such  as  a 
weak  solution  of  iodine,  (gtt.  v-x  to  aqua  f  |  j,)  or  tincture  of 
sanguinaria,  (f3j  to  aqua  f  f  j.)  Sometimes,  sanguinaria, 
myrrh  and  lycopodium,  in  powder,  is  blown  into  the  nostrils. 

The  simple  ozsena  is  treated  by  carefully  removing  the 
pellicle  every  day  or  so,  and  then  using  an  astringent  spray, 
after  which  iodoform  powder  is  blown  into  the  nostrils.  The 
nasal  passages  are  kept  constantly  open  and  dead  bone  is  re- 
moved at  once. 


THE   LARYNGITIS   OF   LEPROSY. 

Dr.  Louis  Elsberg  cleanses  the  larynx  thoroughly  with  the 
spray  and  then  administers  soothing  inhalations.  A  diluted 
emulsion  of  garjun  oil  has  acted  very  well  in  his  hands  as  a 
local  as  well  as  an  internal  remedy.  He  has  had  excellent 
results  from  local  applications  of  a  solution  of  iodoform  in 
sulphuric  ether. 


CHRONIC   BRIGHT  S   DISEASE. 

The  diet  allowed  at  Bellevue  Hospital,  in  this  disease,  con- 
sists mainly  of  milk,  eggs,  butter  and  fresh  fish.  Meat  and 
fried  fats  are  not  allowed.  Those  vegetables  containing  the 
least  amount  of  woody  fibre,  such  as  rice,  potatoes  and  onions, 
are  given  freely.  Asparagus,  turnips,  cabbage  and  beans  are 
not  desirable.  For  the  anaemia,  iron  is  administered  in  the 


32  Notes  of  Hospital  Practice. 

form  of  the  tincture  of  the  chloride,  combined  with   nux 
voraica  and  sweet  spirits  of  nitre : 

R     Tc.  ferri  chlor., 

Tc.  nuc.  vom...., aa  f.^ij. 

Spts.  ether,  nit f^jss.          M. 

Sio. — A  teaspoonful  thrice  daily. 

Cod-liver  oil  is  given  to  increase  the  nutrition,  and  to  com- 
bat the  disease  itself  the  following  prescription  is  employed : 

R     Hydrarg.  chloridi  corrosivi gr.  j. 

Ex.  dig., 

Quinise  sulph aa  gr.  xx.          M. 

Et  in  pil.  No.  xx  div. 
SIG. — One  pill  three  times  a  day. 

To  let  out  the  serum  from  the  legs  punctures  are  made  in 
the  skin  and  the  legs  then  wrapped  in  cloths  wet  in  a  solution 
of  carbolic  acid  in  water,  to  which  essence  of  cinnamon  has 
been  added.  The  patient  is  rubbed  all  over  once  a  day  with 
sweet'  oil. 


THE   MANAGEMENT  OF  THE    DIARRHCEAS  OP  CHILDHOOD. 

Beef  Tea  in  Diarrhoea. — Dr.  Smith  has  found  that  beef  tea 
in  the  diarrhoea  of  children  almost  invariably  acts  as  an  irri- 
tant and  aggravates  the  disease.  Sometimes  it  seems  to  pass 
the  bowels  in  the  same  form  in  which  it  was  taken.  In  any 
case  of  acute  diarrhoea  he  advises  not  to  give  beef  tea. 

The  Reduction  of  Temperature  in  Diarrhoea. — The  best 
means  of  reducing  the  temperature  according  to  Dr.  Smith  is 
by  the  external  application  of  cold.  Since  Kibbe's  .cot  has 
been  devised,  the  immersion  of  the  child  in  a  bath  is  practi- 
cally done  away  with.  Kibbe's  cot  can  be  improvised  easily  ; 
it  is  a  pleasant  and  convenient  way  of  giving  the  wet  pack ; 
is  just  as  eifectual  as  the  bath,  and  has  very  few  of  its  objec- 
tions. Fold  a  small  sheet  so  that  it  will  cover  the  child  from 
the  axillae  to  the  ankles,  place  the  child  on  the  bed,  leaving 


General  Diseases.  33 

the  arms  and  feet  uncovered.  The  axilla  can  be  dried  easily, 
and  the  temperature  be  taken  while  the  child  is  in  the  pack, 
or  the  thermometer  is  introduced  into  the  rectum,  the  most 
accurate  way  of  taking  the  temperature.  Water  of  the  desired 
temperature  is  poured  on  from  a  pitcher.  In  cases  of  slight 
elevation  of  temperature,  say  to  102°  F.,  or  under,  sponging 
off  the  body  with  water  about  the  temperature  of  80°  F.  has 
usually  been  found  to  answer  the  purpose,  and  it  is  done  often 
enough  to  reduce  the  temperature  nearly  to  normal.  But  in 
all  cases  of  an  elevation  of  temperature  above  102°  F.  resort 
is  had  to  the  Kibbe's  cot  or  its  substitute.  Dr.  Smith  always 
remains  and  makes  the  first  application  himself.  The  tem- 
perature of  the  water  used  is  at  first  90°  F.,  then  gradually,  as 
the  child  becomes  accustomed  to  it,  it  is  made  cooler,  until  it  is 
brought  down  to  80°  F.  in  a  few  minutes.  It  has  been  found 
to  be  necessary  where  the  temperature  is  very  high,  or  where 
it  rapidly  rises  after  it  has  been  reduced,  to  apply  the  water 
even  colder  than  80°  so  as  to  reduce  the  temperature  to  99°. 
It  usually  goes  down  still  farther  after  the  child  is  taken  out. 
After  removing  the  sheet,  the  child  is  put  in  a  thin  blanket, 
covered  up  and  allowed  to  go  to  sleep.  In  very  severe  cases, 
where  the  temperature  rises  to  105°  F.,  or  higher,  it  is  neces- 
sary to  apply  the  cold  every  hour  or  two.  In  such  cases  it  is 
not  necessary  to  remove  the  child  from  the  Kibbe's  cot,  but  it 
may  be  allowed  to  remain  there  for  days  if  necessary.  The 
cot  is  made  comfortable  by  folding  a  woolen  blanket  and  put- 
ting it  under  the  child. 

Dysenteric  Diarrhoea, — Dr.  A.  A.  Smith  has  found  small 
doses  of  castor  oil  and  opium,  given  in  mucilage,  an  excellent 
combination  in  this  complaint,  as  in  the  following  prescrip- 
tion: 

R     Ol.  ricini 3J. 

Sacch.  lactis gss. 

Tinct.  opii  camph tt\,xxxij-f3Ja» 

Mucilag.  acacise, 

Aquae  purae aa  q.  s.  ad  Jj.  M 

SiG. — One  drachm  every  two  or  three  hours. 


34  Notes  of  Hospital  Practice. 

The  paregoric  should  be  added  according  to  the  age  of  tho 
child  :  for  a  child  under  a  year,  4  to  8  drops ;  for  a  child  of 
one  to  two  years,  10  drops.  The  diet  is,  at  the  same  time,  to 
be  carefully  regulated.  It  has  been  found  well,  sometimes,  in 
these  case,  to  give  starch-water  enemata.  If  the  enemata  are 
given,  the  paregoric  is  left  out  of  the  castor-oil  mixture,  and 
laudanum  is  put  in  the  enema.  One  or  two  drops  of  lauda- 
num, with  one  to  three  tablespoonfuls  of  starch-water,  are 
given,  according  to  the  age  of  the  child.  The  starch-water  is 
made  about  as  thick  as  thin  cream,  and  given  tepid.  It  is 
repeated  every  three  to  six  hours,  according  to  the  severity  of 
the  attack. 

Flatulent  Diarrhoea. — Dr.  Smith  has  found  the  following 
prescription  an  excellent  one  in  such  cases : 

H     Magnes.  calcin ,"j. 

Spts.  amm.  aromat Tt^xl. 

Tinct.  assafcet gj. 

Anisette £  vi. 

Aq.  cinnamomi q.  s.  ad  %  iv.  M. 

SIG. —  3.j  every  half  hour  until  relieved,  to  a  child  from  three  weeks 
to  four  months  old. 

Two  or  three  doses  will  usually  relieve. 

Koumyss  in  Diarrhoea  Dependent  Upon  Non-Digestion  of 
Sugar. — Dr.  Smith  has  found  this  to  be  a  combination  that  is 
easily  assimilated.  The  koumyss  is  charged  with  carbonic 
acid  gas,  but  children  do  not  take  it  readily  with  the  gas  in. 
It  is  gotten  rid  of  by  taking  the  koumyse  out  of  the  bottle  and 
pouring  it  from  one  pitcher  to  another  a  few  times.  A  small 
quantity  is  kept  out  for  immediate  use,  and  the  remainder  put 
back  into  the  bottle  and  the  bottle  corked  and  put  in  a  cool 
place.  Sometimes  children  who  are  unable  to  retain  anything 
else,  have  been  found  to  take  a  teaspoonful  of  koumyss  at  a 
time  and  digest  it,  and  frequently,  without  any  medicinal 
treatment,  will  recover  under  its  use.  Dr.  Smith  has  found 
that  twelve  hours  is  as  long  as  it  can  be  kept  safely,  after 
once  uncorking  it.  The  child  need  take  no  other  food  while 


General  Diseases.  35 

it  is  taking  the  koumyss.  It  is  itself  food  and  drink.  It  is 
sour,  and  mothers  are  tempted  to  sweeten  it  to  make  it  palat- 
able. It  is  never  to  be  sweetened,  and  never  to  be  given 
within  two  hours  after  any  other  form  of  milk,  and  must  be 
given  cold.  After  the  first  repugnance  to  it,  children  take  it 
quite  readily ;  even  children  as  young  as  six  or  eight  months 
can  be  made  to  take  it  by  taking  advantage  of  their  thirst  and 
giving  it  at  first  in  small  quantities.  Koumyss  may  be  used 
in  many  forms  of  diarrhoea  because  of  its  easy  digestion.  That 
made  by  Dr.  E.  F.  Brush,  of  New  York  city,  is  the  only 
preparation  of  it  which  Dr.  Smith  has  found  reliable. 

Diarrhoea  Due  to  Inflammatory  Disorders. — The  indications 
according  to  Dr.  Smith,  are  to  reduce  the  temperature,  regulate 
the  diet,  surround  the  child  by  the  best  possible  hygiene,  put 
the  warm  applications  over  the  abdomen,  and  give  internally 
a  combination  of  opium  and  camphor.  Tully's  powder,  which 
consists  of  morphine,  camphor,  and  prepared  chalk,  has  been 
found  to  make  a  good  combination.  The  dose  for  an  adult  is 
the  same  as  Dover's  powder.  Ten  grains  contain  one-sixth  of 
a  grain  of  morphine  and  a  little  over  three  grains  of  camphor. 
A  child  three  to  six  months  old  is  given  an  eighth  of  a  grain 
every  two  to  six  hours,  according  to  the  severity  of  the  attack 
and  the  control  the  powder  has  over  it.  A  child  six  to  eighteen 
months  is  given  one-sixth  to  one-fourth  of  a  grain  in  the  same 
way.  After  the  acute  symptoms  have  been  controlled  there 
remains  in  many  cases  a  tendency  to  looseness  of  the  bowels, 
with  very  little  constitutional  disturbance.  The  Tully's  pow- 
der is  then  stopped  and  the  following  given : 

R     Ac.  sulpli.  dil fl\,  xxiv. 

Salicin gr.  xxiv. 

Glycerinse %  iij.          M. 

SIG—  3!.  t.  i.  d. 

This  should  not  be  given  within  a  half-hour  of  the  taking 
of  milk.  The  sulphuric  acid  has  a  tonic  and  astringent  effect, 
and  the  salicin,  besides  its  tonic  effect,  acts  also  as  an  anti-fer- 
mentative. 


36  Notes  of  Hospital  Practice. 

Diarrhoea  Due  to  Errors  in  Diet. — Dr.  Smith  teaches  that  a 
child  under  eight  months  ought  to  have  no  other  diet  than 
milk,  and  that  even  up  to  two  years  milk  should  be  its  main 
diet.  Human  milk  he  regards  as  the  best  during  the  first 
year,  or  until  weaning.  During  the  first  eight  months  cow's 
milk  diluted  one-fourth  with  barley-water  makes  a  fair  diet. 
The  ground  or  crushed  barley  is  boiled  with  water  of  sufficient 
quantity,  so  that  when  cold  it  is  about  as  thick  as  thin  cream. 
The  milk  is  given  about  blood-warm  and  a  little  sweetened. 
Dr.  Smith  has  tried  the  condensed  milk  with  children  thor- 
oughly, and  has  seen  it  tried  in  the  practice  of  others,  and 
protests  against  its  use.  He  thinks  that  children  fed  on  con- 
densed milk,  although  they  may  thrive  well  apparently,  yet 
when  they  fall  ill  show  very  little  resisting  power,  and,  parti- 
cularly when  they  fall  ill  of  diarrhoea,  weaken  very  rapidly 
and  the  diarrhoea  is  apt  to  be  obstinate.  He  holds,  however, 
that  there  are  exceptional  cases  in  which  it  may  be  used,  and 
some  cases  in  which  it  is  desirable  to  use  it  for  a  short  time. 
When  bottle-fed  children  suffer  from  diarrhoea  he  is  accus- 
tomed to  boil  the  milk  and  make  the  barley  water  thinner 
and  give  more  of  it,  say  one-third  barley  water  to  two-thirds 
boiled  milk.  He  has  found  thoroughly  cooked  wheat-flour 
an  admirable  food  for  children  with  diarrhoea,  and  prepares  it 
in  this  way  :  Put  about  two  pounds  of  flour  in  a  muslin  bag, 
tie  a  string  around  the  top  of  it,  and  suspend  it  in  a  kettle  of 
water  and  boil  it  for  five  hours;  then  let  it  get  cold.  Take 
off  the  bag,  cut  off  the  outside  dough  and  grate  it.  Thicken 
boiled  milk  with  this  to  about  the  consistency  of  a  thin  gruel, 
or  about  thick  enough  for  it  to  pass  through  the  rubber  nipple 
of  a  nursing  bottle.  He  thinks  that  all  food  for  children 
should  be  thoroughly  cooked.  Still  more  is  this  to  be  ob- 
served when  they  are  ill  of  diarrhoea.  As  a  rule,  he  teaches 
Jhat  children  suffering  with  acute  diarrhoea  should  be  fed  with 
just  as  little  food  as  will  satisfy  their  hunger.  Often  a  little 
cold  water  will  relieve  their  thirst  and  lessen  the  desire  for 
food.  ^  Icoholic  stimulants  are  avoided  unless  there  is  exhau?- 


General  Diseases.  37 

rion.     Champagne  iced  is  given  in  small  quantities,  if  there  is 
obstinate  vomiting". 

Diarrhoea  Due  to  Prceturnafural  Acidity. — Such  children 
are  given,  with  good  effect,  a  teaspoonful  of  lime-water  three 
times  a  day.  This  is  given  in  two  teaspoon fuls  of  milk. 
Chalk  may  also  be  given.  Dr.  Smith  has  found  the  mist, 
cretce  of  the  Pharmacopoeia  to  be  a  good  preparation.  It  con- 
tains, besides  the  chalk,  gum  arable,  glycerine  and  cinnamon, 
all  of  them  good  in  this  form  of  diarrhoea.  Sometimes  it  has 
been  found  well  to  give  a  laxative,  as  some  of  the  cheesy 
masses  may  have  collected  in  the  intestines,  and  may  be  acting 
as  irritants.  The  indication  is  to  remove  them.  He  has 
found  the  following  prescription  a  better  one  to  give  than  the 
traditional  castor  oil : 

H     Pulv.  rhei.  rad gr.  xv. 

Sodas  bicarb gr.  xxv. 

Aq.  menth.  pip ^  ij.  M. 

SiQ. — One  teaspoonful,  as  a  laxative  to  a  child  from  one  to  four  months 
old. 

This  prescription  gives  the  laxative  effects  of  rhubarb,  with 
its  so-called  secondary  astringent  effects,  as  well  as  the  alkali, 
and  the  sedative,  and  antiseptic  effects  of  the  peppermint. 

In  any  case  of  diarrhoea,  where  there  is  reason  to  believe 
there  is  any  irritant  in  the  intestines,  the  treatment  is  begun 
by  giving  a  laxative  to  remove  it. 

The  Diarrhoea  of  Dentition. — Lancing  the  gums  never  does 
harm.  Dr.  Smith  thinks  it  better  to  err  on  the  side  of  lancing 
them  when  there  may  be  no  necessity,  than  to  fail  to  lance  them 
when  there  might  be  necessity.  He  has  often  seen  a  child 
having  from  ten  to  twelve  movements  a  day  relieved  entirely 
by  lancing  the  gums,  and  with  no  other  treatment.  It  is  in 
these  cases  that  the  bromides  have  proven  so  effectual.  He 
gives  the  following  combination  of  a  bromide  with  mucilage, 
to  a  child  between  six  months  and  a  year;  older  children  a 
larger  dose : 


38  Notes  of  Hospital  Practice. 

R     Sodii  bromid %ss. 

Mucilag.  acacise, 

Aquae  purae aa  q.  8.  ad  %  ij.  M. 

Sio. — A  teaspoonful  every  three  hours. 

The  bromide  diminishes  the  reflex  disturbance,  and  the 
mucilage  is  soothing  to  the  irritated  intestinal  mucous  mem- 
brane. 

General  Hints. — Whatever  the  cause,  Dr.  Smith  insists  that 
all  children,  whether  infants  or  those  older,  be  kept  quiet  when 
suffering  from  diarrhoea.  They  should  be  kept,  according  to 
his  thinking,  in  a  partially  darkened,  quiet  room,  free  from 
noise,  and  all  talk  in  the  room  should  be  avoided,  especially 
when  the  child  is  asleep.  The  nervous  system  in  childhood 
is  so  impressible  that  it  is  easily  disturbed,  and  any  disturb- 
ance of  this  character  aggravates  the  diarrhoea.  Infants  under 
one  year  are  kept  lying  down  as  much  as  possible.  They  are 
not  jolted  up  and  down  as  is  the  custom  of  most  nurses  and 
some  mothers,  in  order  to  amuse  them.  If  the  child  is  under 
one  year  of  age  it  is  placed  on  a  pillow,  if  the  diarrhoea  is 
severe,  as  it  can  be  kept  quiet  more  easily  in  this  way  than 
when  lying  on  the  lap.  Even  in  changing  the  napkin  care 
is  taken  to  move  the  child  as  little  as  possible.  The  room  in 
which  the  child  lies  is  kept  well  ventilated.  Mothers  usually 
are  over-careful  for  fear  the  child  may  take  cold,  and  on  this 
account  are  apt  to  keep  the  room  too  closely  shut  up.  When 
the  child  is  awake  it  is  carried  carefully  into  open  air,  always 
in  the  shade.  Dr.  Smith  believes  salt-air  to  be  beneficial  to 
almost  all  forms  of  diarrhoea  in  children,  and  especially  as 
occurring  in  city  children.  In  all  cases,  in  children  under  a 
year,  if  the  diarrhoea  is  severe,  warm  applications  are  applied 
over  the  abdomen  in  the  shape  of  a  spice  bag.  To  make  this 
take  a  half  ounce  each  of  cloves,  allspice,  cinnamon,  and  anise 
seeds  pounded,  but  not  powdered,  in  a  mortar,  put  these  be- 
tween two  layers  of  coarse  flannel,  about  six  inches  square,  and 
quilt  them  in.  Soak  this  for  a  few  minutes  in  hot  spirits 
(brandy,  or  whiskey,  or  alcohol),  and  water  equal  parts,  and 


General  Diseases.  39 

#pply  it  to  the  abdomen  warm,  renewing  it  when  it  gets  cool. 
In  this  way  it  is  possible,  not  only  to  get  the  effects  of  a  poul- 
tice, but  also  the  sedative  and  antiseptic  effects  of  the  spices. 
Great  heat,  with  influences  that  depress  the  nervous  system, 
bad  hygienic  surroundings,  improper  diet,  too  early  weaning, 
bottle  food,  and  dentition,  are  among  the  causes  that  predis- 
pose to  diarrhoea.  In  all  cases  these  must  be  removed. 

CJiolera  Infantum. — The  two  special  indications  are  to  re- 
duce the  temperature  and  control  the  nervous  manifestations. 
Cold  applications  are  made.  Hypodermic  injections  of  quinine 
and  morphine  are  given  :  To  a  child  of  six  months,  1  grain  of 
quinine  and  about  V200  °^  a  Sra^n  °f  morphine  every  four  or 
six  hours,  according  to  the  indication ;  for  each  additional 
six  months  of  age,  an  additional  £  grain  of  quinine  and  an  ad- 
ditional 1/200  °f  a  grain  of  morphine.  These  are  the  solutions 
of  quinia  and  morphia  which  Dr.  Smith  uses: 

R     Morph.  sulph gr.  ss. 

Aquae  destillat g  j.  M. 

SiG. — Five  minims,  by  hypodermic  injection,  for  a  child  six  months 
old. 

A     Quiniae  sulph jj. 

Ac.  sulph.  dil q.  s. 

Acid  carbol.  cryst gr.  v. 

Aquae  destillat ^  j.  M. 

SiO. — Eight  minims,  by  hypodermic  injection,  for  a  child  six  months 
old. 

Usually,  the  stomacn  is  so  irritable  that  medicines  and  food 
are  both  vomited.  After  the  temperature  is  reduced,  and  the 
nervous  system  is  rested,  small  quantities  of  food  are  given. 
Small  pieces  of  ice  are  also  given  to  allay  thirst. 

The  indications  for  treatment  in  the  exhaustive  form  of 
the  disease  are  thought  by  Dr.  Smith  to  consist  in  checking 
the  enormous  loss  of  fluid  and  in  sustaining  the  patient.  His 
main  reliance  is  on  opium  and  alkalies  and  stimulants. 
Opium,  in  small  doses,  in  addition  to  the  other  effects  claimed 


40  Notes  '<yf  Hospital  Practice. 

for  it,  he  regards  as  a  cardiac  stimulant,  thus  meeting  one  of 
the  chief  indications  in  this  disease. 
The  following  combination  is  good: 

R     Tine.  opii.  camph giij. 

Mist,  cretae j ^iy«  M. 

SIG. — A  teaspoonful  -every  gecond  or  third  hour  to  a  child  of  six 
months. 

Sometimes  nothing  is  retained  by  the  stomach.  In  such 
cases,  it  is  necessary  to  give  the  opium  hypoderrmeally  in 
1/200"gra^n  doses,  without  the-quinia. 

Alcoholic  stimulants  are  given,  and  among  them  brandy  is 
considered  to  be  'best.  Dr.  Smith  gives  5  drops  of  brandy  in 
a  teaspoonful  of  water,  every  hour,  to  a  child  of  six  months, 
if  there  is  great  exhaustion.  This  quantity  is  increased  or 
diminished,  according  to  the  indications.  In  some  eases  of 
cholera  infantum,  a  child  becomes  suddenly  much  more  ex- 
hausted, pulse  becomes  more  rapid,  extremities  are  cold,  per- 
spiration comes  out  freely,  and  the  child  seems  to  be  going 
into  collapse.  An  enema  of  hot  water  sometimes  revives  such 
a  child  Avondi-rfully.  A  good  quantity  of  hot  water  must  be 
used,  say  half  a  pint,  and  a  towel  must  be  held  to  the  anus 
afterward,  in  order  to  have  the  water  retained  as  long  as  pos- 
sible. Along  with  this,  spirits  of  camphor  are  given  internally, 
in  from  6  to  10-drop  doses.  It  may  be  put  in  with  the 
brandy,  and  the  two  given  together  .for  a  few  hours.  In  any 
case  of  diarrhoea,  where  these  symptoms  of  great  exhaustion 
occur  with  the  coldness  of  the  extremities,  the  hot  water 
enemata  may  be  given. 

TYPHOID  FEVER  IN  CHILDREN. 

Dr.  A.  Jacobi  considers  typhoid  fever  in  childhood  as  a 
very  manageable  disease,  if  taken  in  time. 

High  temperature  he  reduces  by  naeai>s  of  the  cold  bath, 
and  if  reaction  is  not  at  once  established  he  plunges  the  child 
into  a  hot  bath,  which  has  the  efifeet  of  restoring  the  circu]ation 


General  Diseases.  41 

on  the  surface  of  the  body  and  thus  enabling  the  blood  to 
throw  off  a  part  of  its  heat.  Where  the  child  will  not  bear  a 
cold  bath,  he  bathes  the  surface  of  the  body  with  cold  water  as 
far  down  as  the  thighs. 

He  regards  cold  packing  of  the  trunk  and  abdomen  as  of 
great  service.  The  child  is  retained  in  the  pack  until  both 
pack  and  surface  become  slightly  warm. 

When  temperature  is  high  he  gives  quinia — from  8  to  15 
grains  daily  in  one  or  two  doses.  If  the  temperature  is  very 
high,  from  12  to  16  grains  are  given  at  a  dose.  He  always 
administers  it  in  solution  and  in  the  form  of  the  muriate,  or 
neutral  tannate. 

He  does  not  hesitate  to  recommend  salicylic  acid  and  salicy- 
late  of  sodium  in  the  reduction  of  high  temperatures.  He 
gives  salicylate  of  sodium  to  a  child  in  doses  of  3  to  6  grains, 
three,  four,  or  five  times  in  the  course  of  twenty-four  hours. 
He  has  sometimes  succeeded  in  reducing  temperature  by  a 
combination  of  quinia  and  salicylic  acid  where  both  remedies 
failed  to  do  so  when  employed  separately. 

Now  and  then  he  uses  digitalis,  in  small  doses,  to  invigorate 
the  heart's  action.  Veratrum  viride  he  does  not  recommend, 
by  reason  of  its  occasional  irritant  effects  upon  the  mucous 
membrane  of  the  stomach  and  intestines. 

He  believes  stimulants  to  be  especially  indicated,  and  gives 
a  baby  one  year  old  an  ounce  of  brandy  or  whiskey  in  the 
course  of  twenty-four  hours.  He  always  gives  them  in  milk, 
water,  or  barley-water,  and  never  alone. 

Camphor  he  regards  as  an  excellent  stimulant,  and  gives 
from  2  to  10  grains  of  camphor,  in  the  course  of  a  day,  to  a 
child  from  two  to  four  years  of  age.  Musk,  also,  he  regards 
as  a  valuable  stimulant.  The  dose  for  a  child  two  years  old, 
is  2  grains,  to  be  repeated  every  hour.  With  it  he  has  ob- 
tained admirable  results,  when  nothing  else  seemed  to  be  of 
any  avail  whatsoever.  When  a  speedy  effect  is  desired,  he 
does  not  rely  alone  upon  the  internal  use  of  stimulants,  but 
proceeds  at  once  to  inject,  hypodermically,  ether,  brandy,  alco- 


42  Notes  of  Hospital  Practice. 

hoi,  or  camphor  dissolved  in  ether,  oil  or  brandy.  He  is  very 
careful  that  the  solution  of  camphor  thus  obtained  is  not  too 
strong,  in  which  case  the  menstruum  is  absorbed  very  rapidly 
and  the  camphor  is  left  remaining  in  the  subcutaneous  tissue. 
Hemorrhage  from  the  bowels  Dr.  Jacobi  treats  by  opium 
and  alum.  In  some  cases  he  has  had  excellent  results  from 
the  steady  application  of  an  ice-bag  over  the  ileo-caecal  valve. 

HEADACHE. 

Nervous  Headache. — Dr.  A.  A.  Smith  has  found  this  form 
will  very  often  yield  to  a  saline  cathartic.  In  addition  to  the 
cathartic,  he  uses  this  formula : 

R     Sodii  bromid „......*, «~. %  vj. 

Elix.  valer.  ammon f^  iv.  M. 

SIG. — A  teaspoonful  every  hour  until  relieved. 

When  the  headache  is  associated  with  anaemia,  he  givej 
iron  in  addition  to  the  above,  and  stimulates  the  heart  with  : 

R  Ammon.  muriat.. .. Jfss. 

Tc.  actaeae  racemos.,  • 

Aquae aa  fg  iij.  M. 

SIG. — A  dessertspoonful,  after  meals,  in  a  wineglassful  of  water. 

Where  there  is  despondency  and  depression  of  spirits,  he 
frequently  uses,  thrice  daily,  a  pill  composed  of  gr.  1/50  of 
phosphorus,  and  gr.  1/g  of  nux  vomica. 

If  there  be  persistent  sleeplessness,  he  gives : 

R     Camph.  pulv gr.  xxv. 

Ext.  cannab.  ind gr.  x. 

Ext.  hyoscyami gr.  xx.         M. 

Et.  in  pil.  No.  r  div. 

SlG. — One  at  night ;  repent  in  two  hours,  if  necessary,  to  product 
sleep. 

Sick  Headache. — Good  results  have  been  obtained  from  the 
use  of  guarana  or  paullinia  sorbillis.  The  latter  is  adminis- 
tered in  powder,  15  grains  being  given  every  fifteen  minutes 


General  Diseases.  43 

until  six  doses  have  been  taken.  It  has  been  found  best  to 
give  it  in  a  little  sweetened  water. 

Malarial  Headache.  —  The  treatment  is  begun  by  adminis- 
tering 15  grains  of  quinia  every  two  hours  before  the  expected 
attack.  If  quinia  fails  to  ward  off  the  attacks,  Fowler's  solu- 
tion and  tincture  of  belladonna  are  given  in  5-drop  doses. 

Headache  Dependent  on  •Gout,  —  This  is  combated  by  means 
of  the  following,- 


R     Yin.  colch.  sem  ..........  ~  ..................  ____  .. 

Lithii  bront, 

Syr.  zingiber  .....  »..^.  ...........  ..  .........  ...,~.  .....  -aa  f^  ss. 

Aq.  cinnnmom  ..................................  q.  s.  ad  f^  vj.  M. 

Sio.  —  A  tablespoonful  in  a  tumblerful  of  Vichy  water  every  few  hours. 

The  Headache  ef  Syphilis,  —  Calomel  is  given  in  doses  of 
the  l/io  °f  a  gra'n  •every  hour  during  the  day.  This  treat- 
ment is  continued  for  two  or  three  days  and  then  stopped,  and 
iodide  of  potassium  given  in  15-grain  doses  at  meals.  This 
amount  is  gradually  increased  until  iodism  is  produced. 

The  Headache  of  Rheumatism*  —  He  uses  the  mild  faradic 
current  to  the  scalp,  and  internally  the  following  : 

R     Potns.  iod., 

Ammon.  muriat  ............  *...«......  .»...„«  .....  -..aa   J^iss. 

Infus.  humuli...^..  .......................................   f^  vj.  M. 

Sio.  —  A  tablespoonful  four  .times  a  day,  in  a  wineglaseful  of  water. 

In  cases  which  do  not  yield  to  this  treatment,  20-grain  doses 
of  the  bromide  of  ammonium  have  been  found  effectual. 

Urcemic  Headache.  —  Dry  cups  are  applied  over  the  region 
of  the  kidneys,  and  the  following  given  internally  : 

R     Potas.  acet  .............  „  ............  «  ..............  «...   ^vj. 

Infus.  digital  ..............................................  ^  vj.  M. 

SIG.  —  A  tablespoonful  every  three  hours. 

The  infusion  is  made  from  fresh  English  leaves.  This 
mixture  is  administered  until  the  kidneys  act  freely.  If  it 


44  Nates  of  Hospital  Practice. 

does  not  relieve  the  headache  within  24  hours,  a  saline  cathar- 
tic is  given.  A  domestic  remedy  often  employed  consists  of 
an  ounce  of  cream-a-tartar  in  a  quart  of  water.  The  whole 
of  this  is  taken  in  the  course  of  10  hours,  and  acts  both  as  a 
cathartic  and  diuretic. 

The  Headache  of  Cerebral  Effusion.  —  If  convulsions  seem 
to  be  imminent,  the  kidneys  are  stimulated  by  means  of  the 
digitalis  and  acetate  of  potassium  mixture,  given  above,  and 
from  12  to  20  ounces  of  blood  are  taken  from  the  region  of 
the  kidneys,  by  means  of  wet  cups. 

The  Headache  of  Acute  Alcoholism.  —  To  remove  the  alcohol 
from  the  intestinal  canal,  give  £  drachm  each  of  rhubarb  and 
calcined  magnesia,  and  then  administer  : 


R     Spts.  ammon.  aromat 

Tc.  camph 

Tc.  hyoscy 

Spts.  lav.  comp  .................................  q.  s.  ad  f^  ij.  M. 

SlO.  —  A  teaspoonful  every  hour,  until  the  headache  is  removed. 

Gr.  ij  of  capsicum  and  gr.  iij  of  quinia  are  then  given 
before  each  meal,  for  several  days. 

If  there  is  sleeplessness,  the  following  formula  can  be 
used  : 

R     Sodii  bromid  .............................................   .^ss. 

Chloral  hydrat  ...........................................   5  ij93- 

Syr.  aur.  cort  .............................................  f^ss. 

Aquae  ..........................  ,  ............................  f,f  iijss.         M. 

SIG.  —  A  tablespoonful  at  night.    To  be  repeated  in  two  hours,  if  neces- 
sary, to  produce  sleep. 

Dyspeptic  Headache.  —  If  there  is  indigestible  food  in  the 
stomach,  an  emetic,  such  as  mustard  and  warm  water,  or  gr. 
xv  of  the  sulphate  of  zinc,  is  given.  If  the  headache  is 
frontal,  10-drop  doses  of  nitro-rauriatic  acid,  well  diluted,  are 
given  after  meals.  If  the  pain  is  located  about  the  roots  of 
the  hair,  gr.  xx  of  the  bicarbonate  of  sodium  or  magnesium, 
are  given  before  meals. 


Genwal  Disease*.  45 

When  the  pain  spreads  over  the  entire  bead,  Dr.  Smith 
gives: 


R     Sod.  bicarb  .........  ----  .............  ------  ..... 

Ac.  nitro-mur.  dil  .......................................    f  %  ij. 

Tc.  nuc.  vora  ............  ~  ........  .....................  ...  fjjss. 

Syr.  aurant.  cort  ..........................................   f^^j- 

Aquae  ..............................................  q.  s.  ad   f^  vj.  M. 

SiO.  —  A  tablespoonful,  after  meals,  in  a  wineglassful  of  water. 

If  there  is  gastric  pain,  a  mustard-plaster  is  applied  to  the 
epigastrium.  If  flatulence  is  troublesome,  bismuth  and  mix 
vomica  are  given  combined  : 

R     Bismuth,  subcarb....  ...........  *  ........  *  ........  .  .......  3Jss. 

Tc.  nuc.  vom  ......  ....................  ~  .....  „  ...........   f^jss- 

Tc.  card,  co., 

Spts.  lav.  comp  ..............................  aa  q.  B.  ad   f  ,f  iv.  !M 

SiO.—  Two  teaspoenfuls,  before  meals,  in  a  wineglassfal  of  water 

If  there  is  constipation,  the  following  pill  is  given: 

R     Aloes  pulv  ......................  »  ......  ......  .......  ......  3  es. 

Ex.  nuc.  vom.  .......  .....  ..........  ...................  ~.  gr.  v. 

Ex.  belladon  -------  ..  ...............................  _________  gr.  iv.          M. 

Et.  in  pil.  No.-xv  div. 

In  other  forms  of  headache  associated  with  indigestion,  a 
single  drop  of  the  tincture  of  nux  vomiea  is  given  every  fifteen 
minutes  until  10  or  15  drops  have  been  taken. 

Where  headache  depends  on  delayed  stomachic  digestion,  | 
a  drachm  of  saccharated  pepsin,  in  a  wineglassful  of  sherry 
wine,  is  effectual. 

The  Headache  of  Acute  Cerebral  Congestion.  —  The  patient 
is  kept  in  a  darkened  room,  perfectly  quiet,  and  cold  and 
evaporating  lotions  are  applied  to  the  head.  A  saline  cathar- 
tic- is  first  administered,  and  then  the  following  : 

R     Sodii  bromid 

Fl.  ex.  ergot  ............  ~  ......................  „ 

Syr  zingiber  ...........  ~  .....  ........  ~  ...................   f^ss. 

Aq.  aurant.  flor  ..................................  q.  s.  ad   f.^  iv. 

Sio.  —  A  tablespoonful  every  two  hours. 


46  Notes  of  Hospital  fracace. 

If  the  skin  is  hot  and  dry,  ami  the  pulse  full  and  rapid,  2 
drops  of  Fleming's  tincture  of  (»he  root  of  aconite  are  given 
every  two  hours  until  the  heart's  action  is  sensibly  reduced. 

The  Headache  of  Passive  Cerebral  Congestion.  —  The  heart's 
action  is  stimulated  by  the  use  of  the  following  : 


R     Tc.  digital 

Spts.  ammo,  aromat  ..............  . 

Spts.  lav.  comp., 

Syr.  simp  .....................................  aa  q.  8.  ad  f%  iij.  M. 

Sio.  —  A  teaspoonful  every  four  hours. 

The  Headache  of  Cerebral  Anosmia.  —  The  patient  is  al- 
lowed to  inhale  from  3  to  5  drops  of  the  nitrite  of  amyl, 
placed  on  a  piece  of  cotton  and  applied  to  one  nostril  while 
the  other  is  closed. 

When  associated  with  nervous  exhaustion,  this  formula  ia 
osed  : 

H     Strych.  sulph  .............................................  gr.  as. 

Tc.  ferri  chlor.  ............................................  ^3lj- 

Glycer  ......................................................  f^sa. 

Infos,  gent  .......................................  q.  8.  ad  f^  vj.  M. 

Sio.  —  A  tablespoonful,  after  meals,  in  a  wineglassful  of  water. 

A  tablespoonful  of  brandy  after  each  meal,  and  a  glass  of 
champagne  at  dinner,  are  often  of  great  advantage  in  these 
cases. 

The  Headache  of  Cerebral  Tumors.  —  The  iodide  of  potas- 
sium is  the  indication  followed. 

The  Headache  of  Cerebral  Softening.  —  This  is  palliated  by 
opium  and  rest.  Ergot  in  large  doses  —  f3j-f3iv  of  the 
fluid  extract  thrice  daily  —  has  been  employed  in  several  cases 
of  this  kind,  by  Dr.  Smith,  with  admirable  effect. 


CATARRHAL    INFLAMMATION   OF   THE   MIDDLE   EAR. 

Dr.  Samuel  Sexton  treats  these  cases  by  means  of  an  instru- 


Notes  of  Hospital  Practice.  47 

merit  consisting  of  a  soft  rubber  bulb,  connected  by  a  flexible 
tube  with  a  hard  rubber  nozzle  which  is  somewhat  olive-shaped 
and  adapted  to  fit  into  the  entrance  of  the  external  auditory 
meatus.  When  used,  the  nozzle  of  the  instrument  is  held  to 
the  ear  with  the  left  hand  of  the  operator  and  pressed  against 
the  opening  with  sufficient  force  to  make  the  fitting  as  nearly 
air-tight  as  possible;  while  the  bulb  is  held  in  the  right  hand, 
to  be  manipulated  as  desired.  Care  is  always  had  in  using 
this  instrument  not  to  employ  two  much  force  in  stimulating 
the  membrana  tympani.  When  the  instrument  is  used  for 
suction,  so  as  to  draw  the  membrane  out  as  far  as  possible,  the 
ball  is  simply  collapsed  by  pressure  of  the  right  hand  before 
the  nozzle  is  applied  to  the  ear.  Upon  removing  the  pressure 
of  the  hand,  the  bulb,  by  its  own  elasticity,  gradually  resumes 
its  expanded  condition,  thus  rarefying  the  air  in  the  external 
meatus.  If  it  is  desired  to  give  the  membrana  tympani  and 
ossicula  motion,  the  bulb  is  alternately  compressed  and  ex- 
panded while  the  nozzle  is  in  contact  with  the  ear.  Where 
inflammation  is  high,  leeches  are  applied  and  warm  water 
instillations  are  practiced. 

CHRONIC  BRIGHT'S  DISEASE. 

Milk  is  used  freely.     The  diet  is  rendered  noBrnitrogenous  - 
as  far  as  possible.     Cod-liver  oil  is  given  in  combination  with 
the  following  mixture : 

R     Tr.  ferri  muriat., 

Tr.  nucis  vom «...   aa  gtt.  x.\ 

Spts.  etheris  nitrosi f^j.  M.  . 

SiG. — To  be  taken  thrice  daily. 

if  the  patient  is  troubled  with  gastritis,  the  iron  and  cod 
liver  oil  are  stopped  and  cream  of  tartar  administered  as  a 
purge.     I^arge  doses  of  pepsin  and  of  the  oxalate  of  cerium 
are  used  to  quiet  the  stomach.     The  specific  treatment  of  this 
disease  at  Bellevue  Hospital  consists  of  the  following : 


48  General  Diseases, 

&     Hydrarg.  bichlor gr.  J^. 

Quin.  sulph aa  gr.  j.  M. 

SIG. — To  be  given  thrioe  daily. 

The  skin  is  freely  rubbed  with  olive  oil  twice  daily. 

CATARRHAL   LARYNGITIS. 

To  break  up  the  tendency  to  a  continuation  of  the  disease, 
after  recovery  from  the  attack,  the  child  is  given  the  follow- 
ing mixture,  at  Bellevue  Hospital: 

R     Hydrarg.  chlor.  mit., 

Quiniae  sulph aa  gr.  j.  M. 

SIG. — To  be  taken  three  times  a  day  until  6  grains  of  the  calonuJ 
have  been  administered. 

THE  GENERAL  TREATMENT  OP  CONSTIPATION 

Constipation  Dependent  Upon  Deficient  Secretion. — Dr. 
Thomson  believes  that  the  use  of  cathartics  or  of  medicines 
calculated  to  stimulate  nerve  action,  only  does  harm  in  this 
condition.  The  best  results  have  followed  the  use  of  large 
quantities  of  water.  His  patients  are  directed  to  take  two 
tumblerfuls  of  water  upon  rising.  A  small  amount  of  com- 
mon salt  may  be  added  to  this  water  to  increase  its  laxative 
effect.  He  has  found  that  the  addition  of  small  quantities  of 
quinia  to  salines  increases  their  power;  for  instance,  he  gives 

R     Mag.  sulph ~. ~ 3j; 

Quin.  sulph «.. gr.  j, 

in  a  tumblerful  of  water  every  morning.     He  does  not  plaof 
much  confidence  in  the  value  of  fruits  as  laxatives. 
Flatulence  is  overcome  by  the  following : 

R     Assafoet » gr.  IT. 

Saponis gr.  ix.          M. 

SIG. — To  be  taken  when  necessary. 


Notes  of  Hospital  Practice.  49 

Constipation  Due  to  Want  of  Peristaltic  Action. — A  sitz- 
bath  is  ordered  every  night,  the  water  used  being  as  cold  as 
the  patient  can  bear;  or,  upon  rising  in  the  morning,  the  spine 
and  abdomen  are  sponged  with  cold  water.  In  other  cases, 
great  benefit  is  derived  from  dashing  water  against  the  abdo- 
men while  the  patient  stands  up.  Nux  vomica,  combined 
with  soap  and  rhubarb,  has  proved  very  serviceable.  The 
application  of  the  faradic  current,  one  pole  of  the  battery  being 
placed  over  the  spine,  and  the  other  passed  up  and  down  over 
the  abdominal  walls,  has  often  been  of  great  benefit.  In  still 
other  cases,  the  health-lift  is  recommended. 

Constipation  Due  to  Chronic  Inflammation  of  the  Rectum. — 
The  rectum  is  emptied  by  means  of  enemata.  When  it  is 
thoroughly  cleansed  out,  strychnia  is  injected  locally,  a  fold 
of  the  mucous  membrane  being  drawn  down  and  the  needle 
inserted.  This  same  hypodermic  method  has  given  the  most 
excellent  results  in  Dr.  Thomson's  hands  in  cases  of  constipa- 
tion accompanying  enlarged  prostate.  In  every  instance  the 
rectum  is  first  thoroughly  emptied  by  means  of  an  enema. 
Kissengen  water  is  prescribed  in  the  morning,  and  a  supposi- 
tory of  belladonna,  or  stramonium,  used  at  night.  Faradiza- 
tion along  the  course  of  the  colon,  and  hip-baths>.are  also  of 
service. 

Constipation  Following  Febrile  Diseases  is  treated  by  means 
of  the  compound  jalap  powder. 

Constipation  Associated  with  Chlorosis. — Dry  heat  is  applied 
to  the  feet  and  hands.  In  addition  to  the  dry  heat,  the  feet 
and  arms  are  wrapped  in  cloths  dipped  in  a  solution  of  capsi- 
cum. The  same  application  is  made  over  the  abdomen. 
After  these  measures  have  been,  continued  for  some  time, 
cathartics  are  administered,  the  one  most  generally  employed 
at  Bellevue  Hospital  being  the  compound  rhubarb  pill.  Of 
these,  three  are  given  at  night,  twice  a  week,  or  given  every 
night  until  the  bowels  have  been,  rendered  soluble.  Iron  is 
not  used  until  the  bowels  have-  been  rendered  soluble.  The 


50  Notes  of  Hospital  Practice. 

form  in   which   it  is  most  frequently  prescribed  is  the  fol- 
lowing : 


R     Potas.  bicarb...' „ ......... 

Ferri  sulph., 

Ex.  nucis  vom ........  aa  gr.  r.  M. 

Et  in  pil.  No.  xx  div. 
Sio. — One  after  each  meal. 

To  restore  tone  to  the  muscular  coat  of  the  intestines,  bella- 
donna and  nux  vomica  are  thus  combined  with  eoloeynth  : 

R     Ext.  belladon .„„.  gr.  v. 

Ext.  nucis  vom ». gr.  x. 

Ext.  eoloeynth.  co .„ 3J.  M. 

Et  in  pil.  No.  xx  div. 
SIG. — One  at  bedtime. 

If  the  eoloeynth  causes  griping,  it  is  prevented  by  the 
addition  of  3  ij  of  the  bicarbonate  of  sodium  and  the  divi- 
sion of  the  above  mass  into  40  pills,  the  dose  being  doubled, 
i.  e.}  two  pills  are  to  be  administered  to  the  patient  at  bed- 
time, instead  of  one. 

FAVTJS. 

Dr.  H.  G.  Piffard  removes  all  the  superficial  crusts  by  scrap- 
ing  them  off  or  digging  them  out  with  a  pen-knife  or  small 
spatula.  He  first,  however,  loosens  them  by  means  of  poul- 
tices or  frictions  with  oil.  After  the  crusts  are  all  removed, 
(he  parts  are  smeared  with  sulphur  or  turpeth  ointment  (3  to 
5  per  cent.)  The  hairs  are  then  pulled  out,  one  by  one,  by 
means  of  a  properly  constructed  forceps.  After  the  hairs  have 
been  pulled  out,  a  solution  of  the  bichloride  of  mercury  (2  or 
3  grains  to  the  ounce)  is  thoroughly  rubbed  in. 

DISEASES   OF  THE   HEART. 

Valvalar  Lesions. — Dr.  Flint  advises  this  class  of  patients 
not  to  overtax  the  heart,  allowing  only  just  such  an  amount  of 
physical  exertion  as  can  be  done  with  entire  comfort.  He 


General  Diseases.  61 

is.ys  down  the  same  rule  with  regard  to  mental  excitement. 
When  there  is  co.-existent  dilatation  of  the  left  ventricle  aud 
consequent  dropsy,  hydrogogues  and  diuretics  are  prescribed. 
To  relieve  dyspnoea,  opiates  and  ether  are  administered.  When 
the  action  of  the  heart  is  feeble  and  irregular,  from  10  to  16 
drops  of  the  tincture  of  digitalis  are  given  at  short  intervals- 
The  chalybeates  are  indicated  if  anaemia  be  present. 

Aortic  Lesions.  —  He  uses  digitalis  with  a  certain  amount  of 
reserve  in  the  treatment  of  aortic  lesions. 

Angina  Peetoris.  —  He  treats  the  paroxysms  by  the  free  ex- 
hibition of  alcoholic  or  ethereal  stimulants  —  either  brandy  or 
Hoffman's  anodyne;  to  this  a  few  drops  of  laudanum  are 
added  with  advantage.  Nitrite  of  amyl  is  also  inhaled  and 
generally  stops  the  spasms  promptly. 


CONTUSIONS. 

This  is  the  method  of  treatment  employed  at  Bellevue  Hos- 
pital. The  parts  are  fomented  continually  with  simple  hot 
water  until  the  pain  ceases,  and  the  contusion  is  then  kept  wet 
with  the  following  lotion; 

R     Ammon.  rauriat  ..........  ...  ............  ......  ......  ...  .....   ^  ij. 

Aceti, 

Aquse..  .....  .....  ..............  .........  ...  .......  ,  .....  ,..aa  f  J  ij.  M. 


SCARLET   FEVER. 

The  diet  upon  which  all  Dr.  Thomson's  patients  are  placed, 
consists  of  milk,  either  alone  or  witli  lime-water.  In  a  certain 
class  of  cases  he  employs  the  carbonate  of  ammonium  freely, 
but  his  general  method  of  treatment  until  quite  lately  has 
been  by  the  chlorate  of  potassium  and  dilute  muriatic  acid 
(gr.  Ixxx  of  the  former  and  f3ij  of  the  latter,  during  the 
course  of  the  24  hours,  diluted  with  Oij  of  water.)  Now  he 
substitutes  the  bromide  of  potassium  for  the  chloride.  The 


52  Notes  of  Hospital  Practice. 

solution  employed  consists  of  a  saturated  solution  of  the  bro- 
mide of  potassium  in  water,  to  f  1  ij  of  which  f  j  of  bromine  is 
added  very  slowly,  the  bottle  being  shaken  constantly  while 
the  combination  is  being  made.  Dr.  Thomson  has  found  it 
better  to  add  half  of  the  quantity  of  the  bromine  first,  and 
then  to  let  the  bottle  stand  for  an  hour  or  more  before  the 
remainder  is  added.  When  the  bromine  is  dissolved  in  this 
manner,  the  bottle  is  filled  with  water  until  a  4-ounce  mixture 
is  made.  For  internal  administration  f 3j  of  the  solution  to 
f  ij  of  water  is  used,  and  of  this  a  teaspoonful  is  given  in  a 
tablespoonful  of  sweetened  water,  p.  r.  n.  The  solution  is  kept 
in  a  dark  place.  Equal  parts  of  this  solution  and  of  glycerine 
are  used  as  a  local  application. 

He  advises  occasional  purges  composed  of  gr.  iij  of  calomel 
and  gr.  v  of  jalap.  Rapid  rise  of  temperature  to  104°-106° 
he  meets  by  the  douche  of  ice- water  to  the  head  or  by  the  cold 
pack.  He  does  not  recommend  the  cold  bath.  His  way  of 
administering  the  wet  pack  is  this — he  takes  a  sheet,  wrings 
it  from  water  at  the  ordinary  temperature,  wraps  the  child  in 
it  and  over  that  lays  one  wrung  from  ice-water. 

He  recommends  that  from  the  very  inception  of  the  disease 
the  body  be  oiled  over  three  times  a  day;  this  relieves  the  itch- 
ing and  reduces  the  temperature.  To  relieve  nephritis  he 
employs  the  hot  water  pack,  dry  cups,  counter-irritation  over 
the  kidneys,  digitalis  and  warm  water  injections. 

RUM   STOMACH. 

Dr.  Alfred  Loomis  prescribes  equal  parts  of  the  compound 
tincture  of  gentian  and  of  columbo  with  gtt.  v— xv  of  the 
tincture  of  nux  vomica,  before  meals.  He  also  employs  occa- 
sional aloetic  and  mercurial  purges. 

EMPHYSEMA. 

Dr.  Francis  Delafield  prescribes,  when  iodide  of  potassium 


General  Diseases.  53 

and  all  other  remedies  fail,  gtt.  xxv  of  aromatic  sulphuric 
acid  four  times  a  day. 


DIABETES    INSIPIDUS  IN   CHILDREN, 

Dr.  Delafield  administers  the  fluid  extract  of  belladonna  jn 
email  doses,  or  in  some  cases  uses'  gtt.  v  of  a  gr.  j  to  the  f  §  j 
solution  of  atropia  once  a  day.  If  well  borne  the  dose  is  in- 
creased to  5  drops  twice  a  day,  and  so  on  until  gtt.  vij  are 
given  every  three  hours.  At  the  same  time  a  teaspoonful  of 
cod-liver  oil  is  given  thrice  daily,  or  if  it  disagrees  with  the 
stomach,  the  ail  is  well  rubbed  into  the  skin  once  a  day.  As 
a  hygienic  measure  the  child  is  thoroughly  washed  every  day 
with  warm  water  and  soap,  and  is  clothed  in  flannels  whids 
cover  the  whole  body, 

EPB3TAXI&. 

Ten-drop  doses  of  Squibb's  fluid  extract  of  ergot  are  given 
after  meals  with  the  same  amount  of  the  muriate  of  iron.  This 
treatment  has  been  followed  by  excellent  results  in  the  warda 
of  Belle vue  Hospital. 

\, 

DISINFECTANT  AND  ANTISEPTIC  COUGH   MIXTURE, 

This  is  very  much  used  at  Bellevue  Hospital. 

R     Potas.  iod ,.^. ..._,. :jj. 

Acid.  nit.  dil.... „ ^iij- 

Tr.  belladon fjjj. 

Acid,  salicyl .., „., £j. 

Aq.  camph q.  s.  ad  f^  iij.  )f. 

Sie. — Two  teaspoonfrjs  in  water  three  or  four  times  daily. 


SURGICAL  AND  VENEREAL  DISEASES. 


FISSURE   OF   THE    RECTUM. 

In  young  subjects,  Dr.  Erskine  Mason  keeps  the  bowels  in 
a  soluble  condition,  and  applies,  locally,  zinc  or  stramonium 
ointment,  in  combination  with  belladonna  or  opium ;  or  ha 
pencils  the  fissure  to  its  bottom  with  a  fine  point  of  nitrate  of 
silver,  or  with  nitric  acid. 

His  radical  method  of  treating  this  painful  affection,  con- 
sists in  dividing  the  mucous  membrane  and  some  of  the  fibres 
of  the  sphincter  muscle,  with  a  knife,  being  careful  to  divide 
the  nerve  filament  involved.  In  some  cases,  he  is  able  to 
effect  a  cure  simply  by  over-distension  of  the  rectum.  The 
thumbs  are  introduced,  back  to  back,  into  the  rectum,  when 
forcible  distension  is  made  towards  the  tuber  ischii,  and  car- 
ried to  the  fullest  extent  possible.  The  cutting  operation  is 
thus  performed :  the  parts  are  put  upon  the  stretch  by  intro- 
ducing a  speculum,  and  when  they  are  moderately  tense,  the 
knife  is  drawn  through  the  base  of  the  fissure.  As  after- 
treatment,  the  patient  is  kept  in  bed  for  a  day  or  so,  and  the 
bowels  are  quieted  by  means  of  an  opiate.  Before  the  bow- 
els are  allowed  to  be  moved,  an  enema  of  sweet  oil  is  given. 


LUXATION   AT  THE    HIP- JOINT. 

The  patient  is  placed  on  his  back,  on  the  floor;  the  femur 
is  flexed  upon  t*he  abdomen,  until  it  is  brought  at  right  angles 
with  the  pelvis;  then,  standing  astride  of  the  patient,  the 
assistant  (Bellevue  Hospital)  clasps  his  hands  under  the  legs, 
close  up  to  the  thighs,  and  suspends  the  body.  When  the 

(54) 


Surgical  and   Venereal  Diseases.  55 

patient's  body  has  been  raised  free  from  the  floor,  the  sound 
limb  is  so  balanced  against  the  leg  of  the  surgeon  that  the 
entire  weight  of  the  patient's  body  can  be  utilized  as  an 
extending  force  upon  the  dislocated  limb,  and  assisted,  per- 
haps, by  a  trifling  rotation,  will  draw  the  acetabulum  over  the 
head  of  the  bone. 

N.EVTJS. 

Dr.  R.  W.  Taylor  employs  the  electric  needle,  for  the  pur- 
pose of  destroying  these  growths.  Dr.  A.  C.  Post  believes 
that  if  there  is  no  tendency  to  spread,  the  nsevi  had  better  be 
let  alone,  but  that,  when  they  manifest  a  tendency  to  spread, 
they  should  be  at  once  removed.  In  this  operation,  he  em- 
ploys an  instrument  consisting  of  six  needles,  each  about  the 
size  of  a  fine  knitting-needle,  and  without  points.  Thesw 
needles  are  inserted  in  a  handle,  and,  about  half  an  inch  from 
their  outer  extremities,  are  passed  through  a  bar  containing 
two  rows  of  holes.  Each  row  contains  three  needles,  and  the 
perforations  are  separated  nearly  one-fourth  of  an  inch  in 
each  direction.  By  using  this  instrument,  the  operation  is 
greatly  facilitated,  and  the  heat  is  better  retained  in  this  bun- 
dle than  it  would  be  in  a  single  needle. 

POTTS'   DISEASE  OF  THE  SPINE. 

The  plaster-of-paris  dressing  is  thus  applied  at  Bellevne 
Hospital :  the  patient  puts  on  a  light  wrapper,  and  then,  by 
means  of  a  pulley  attached  to  straps  which  pass  through  the 
axillae  and  are  secured  to  a  cross-bar  over  the  head,  is  com- 
pletely suspended.  In  this  way  the  weight  of  the  body  is 
made  to  act  as  a  counter-extending  force,  and  removes  all 
pressure  from  the  diseased  surfaces  of  the  bones.  While  thus 
suspended,  the  wrapper  is  drawn  down  smoothly  over  the 
trunk  and  hips.  Then  with  a  roller  bandage  filled  with  plas- 
ter a  beginning  is  made  2  or  3  inches  below  the  crests  of  the 
ilii,  sufficient  to  secure  a  firm  hold  upon  the  pelvis.  Two  or 


56  Notes  of  Hospital  Practice. 

three  extra  turns  of  the  roller  are  first  made  at  this  point  and 
the  body  is  then  embraced  by  successive  turns  until  the  entire 
trunk  is  encased  to  the  arm-pits.  If  the  disease  is  high  up  in 
the  dorsal  region,  the  bandage  is  carried  over  each  shoulder, 
like  a  pair  of  suspenders.  A  roll  of  cotton  is  placed  upon 
each  side  of  the  spinal  cord  opposite  the  seat  of  disease.  Two 
or  three  rollers,  supported  by  fine  strips  (made  rough  like  a 
grater  to  prevent  them  from  slipping,)  make  a  substantial 
jacket.  The  cotton  padding  is  not  allowed  to  be  excessive,  as 
it  would  thus  obliterate  the  irregularities  of  the  surface  almost 
entirely,  which  is  just  the  thing  to  be  avoided,  for  it  is  the 
gentle  moulding  of  the  jacket  to  the  depressions  and  elevations 
of  the  surface  of  the  body  that  enables  it  to  accomplish  its 
work  and  be  worn  without  complaint.  When  abscesses  are 
present,  windows  are  made  in  the  jacket  through  which  they 
can  discharge. 

STRICTURE. 

Dr.  H.  B.  Sands  believes  internal  urethrotomy  to  be  appli- 
cable chiefly  to  close  strictures  and  as  an  auxiliary  to  dilatation. 
He  is  a  firm  believer  in  gradual  dilatation  as  by  far  the  best 
method  of  treating  the  majority  of  strictures.  He  considers 
the  use  of  sounds  exceeding  25  mm.  to  be  very  rarely  neces- 
sary either  as  a  means  of  diagnosis  or  of  treatment.  The  prac- 
tice of  slitting  up  the  meatus  he  denounces  as  irrational. 

Dr.  F.  N.  Otis  regards  gradual  dilatation  as  only  a  tem- 
porary expedient.  He  does  not  think  that  section  should  be 
limited  to  close  strictures.  In  all  cases  he  insists  upon  the 
prompt  restoration  of  the  urethral  calibre. 

Dr.  F.  J.  Bu instead  regarded  internal  urethrotoray  as  pre- 
ferable, to  gradual  dilatation  in  the  treatment  of  stricture. 
Some  time  ago  he  was  in  the  habit  of  treating  urethral  stric- 
tures by  means  of  Holt's  divulsor,  but  latterly  and  up  to  the 
time  of  his  death,  he  discarded  this  method  of  treatment 
entirely.  He  found  that  internal  urethrotomy  was  produclisre 


Surgical  and  Venereal  Diseases.  57 

of  better  results  when  carried  to  a  considerable  extent  than 
when  more  limited.  In  several  cases  he  cut  so  as  to  admit  a 
35  or  40  mm.  French  scale.  He  thought  that  sounds  larger 
than  25  mm.  were  constantly  needed  in  practice.  He  thought 
that  the  meat  us  was  slit  up  entirely  too  much,  but  he  had  never 
seen  any  bad  results  follow  such  slitting. 

Dr.  E.%L.  Keyes  thinks' that  internal  urethrotomy  is  better 
than  dilatation  in  strictures  situated  in  the  anterior  portion  of 
the  urethra.  In  the  treatment  by  dilatation  he  prefers  instru- 
ments below  rather  than  above  30  mm.  Strictures  in  the 
deeper  portions  of  the  urethra  he  treats  by  gradual  dilatation 
and  traumatic  linear  strictures  by  external  section. 


STRANGULATED   AND   INCARCERATED   HERNIAS. 

Dr.  Frank  Hastings  Hamilton  has  reached  the  following 
conclusions  regarding  posture  in  the  treatment  of  strangulated 
and  incarcerated  hernias: 

1.  Taxis  is  of  prime  importance. 

2.  Internal  traction  is  only  second  to  this  in  value.     This 
is  accomplished  by  securing  the  paralysis  of  the  abdominal 
muscles  ana  exciting  peristalsis  in  the  intestines. 

3.  Chloroform,  hot  baths  and  other  similar  agents  are  the 
best  means  for  accomplishing  muscular  relaxation,  peristalsis 
and  anti-peristalsis. 

4.  Ice  can  only  relieve  the  "button-holing"  when  this  is 
due  to  congestion,  and  when  it  is  applied  very  early.     Opium 
is  also  of  a  somewhat  limited  application. 

5.  Emetics  are  of  service  in  causing  an  upheaval  of  the 
viscera  and  in  exciting  peristalsis. 

6.  Purgatives  act  by  causing  peristalsis  above,  and  anti- 
peristalsis  below,  the  seat  of  stricture. 

7.  Stimulating  eneraata  and  enemata  of  tobacco  also  pro- 
duce  peristalsis,  and  are  both  direct  and  indirect   in  their 
effects. 


68  Notes  of  Hospital  Practice. 

8.  All  positions  of  the  patient  are  beneficial  in  which  the 
viscera  are  drawn  unwards ;  and  that  is  likely  to  be  of  the 
most  service  which  causes  the  most  efficient  inward  traction, 
at  the  same  time  that  it  does  not  interfere  with  the  applica- 
tion of  taxis. 

PROLAPSE   OF   THE   RECTUM. 

In  recent  cases,  Dr.  Abram  Jacobi  finds  an  injection  of  ice- 
water  sufficient  to  effect  a  cure.  Where  this  fails,  he  resorts 
to  zinc  or  alum.  He  finds  the  nitrate  of  silver,  either  in  stick 
or  solution  of  varying  strength,  an  excellent  remedy.  In 
whichever  form  used,  its  action  is  immediately  neutralized. 
Otherwise,  it  may  give  rise  to  extreme  tenesmus.  The  actual 
cautery  is  employed  with  good  effect  in  some  cases.  When 
there  is  only  a  paralysis  of  the  sphincter  ani,  mix  vomica  or 
strychnia  are  employed.  He  very  often  employs  strychnia 
hypodermically,  using  about  1/gQ  of  a  grain  every  day.  An 
ointment  which  he  very  often  uses  is  one  composed  of  3  j  of 
the  alcoholic  extract  of  nux  vomica  rubbed  up  with  an  ounce 
of  fat. 


LIGATION  OF  THE  LINGUAL  ARTERY  IN  THE  'REMOVAL 
OF  CANCER  OF  THE  TONGUE. 

Dr.  George  F.  Shrady  reaches  the  following  conclusions  in 
this  connection : 

1.  Cancer  of  the  tongue,  whenever  possible,  should  be  re- 
moved through  the  mouth. 

2.  Ligation  of  the  lingual  artery  should  always  precede 
this  operation. 

3.  This  ligation  should  be  performed  near  the  origin  of  the 
vessel. 

4.  The  use  of  the  scissors  and  knife  places  the  wound  in  a 
condition  more  favorable  for  rapid   healing  than  when  the 
ecraseur  or  any  variety  of  cautery  is  used. 


Surgical  and  Venereal  Diseases.  59 

5.  Ligation  of  the  lingual  helps  to  prevent  the  return  of 
the  disease. 


8CIRRHUS  OF  THE  MAMMA. 

Dr.  C.  K.  Briddon  operates  by  the  electrolytic  plan  of 
treatment.  A  needle,  attached  to  the  negative  pole  of  a 
Drescher  constant  battery,  is  plunged  into  the  tumor  near  its 
base ;  a  sponge  electrode  attached  to  the  positive  pole  is  ap- 
plied to  the  opposite  side  of  the  tumor,  and  the  current  from 
ten  cells  set  in  action.  No  anaesthetic  is  used. 


EXTIRPATION   OF  THE   RECTUM   FOR   CANCER. 

This  operation  is  performed  as  follows,  by  Dr.  Keyes  : 
The  mucous  membrane  is  incised  from  the  tumor  downwards, 
and  the  incision  carried,  externally,  through  the  skin  only  as 
far  as  the  tip  of  the  coccyx.  A  stout  needle  and  ligature, 
carrying  the  wire  of  the  ecraseur,  are  then  passed  from  near 
the  tip  of  the  coccyx,  upwards,  outside  of  the  gut,  above  the 
disease,  then  through  the  wall  of  the  bowel  and  out  at  the 
anus.  The  tissues  included  in  the  loop  of  the  wire  are  then 
slowly  divided.  The  diseased  portion  of  the  gut  is  now 
drawn  well  down,  and  stout  knitting-needles  are  thrust 
through  the  healthy  tissue,  beyond  it,  on  each  side,  suc- 
cessively. The  loop  of  the  ecraseur  is  then  carried  round, 
above  the  needles,  and  the  whole  mass  thus  removed.  No 
antiseptics  are  used. 

FIBROUS  ANCHYLOSIS. 

Inflammatory  action  is  subdued,  by  Dr.  Lewis  A.  Sayre,  by 
rest  in  bed  and  continued  application  of  cold  to  the  inflamed 
parts  by  means  of  ice-bags.  When  inflammatory  action  is 
subdued,  the  patient  is  placed  upon  an  instrument  consisting 
of  a  pelvic  belt,  with  perineal  bands;  a  long  bar,  with  a  foot- 


60  Notes  of  Hospital  Practice. 

piece  and  adjustment,  for  extension  ;  a  knee-cap,  and  a  mov- 
able joint,  opposite  the  hip,  for  flexion,  extension  and  abduc- 
tion. The  movable  joint  is  so  arranged  that  abduction  and 
rotation  of  the  limb  outwards  can  be  effected  at  the  same 
time.  The  most  admirable  effects  have,  in  most  cases,  fol- 
lowed the  use  of  this  apparatus. 

CHRONIC  SYNOVITIS. 

Decided  benefit  has  been  obtained,  in  the  sub-acute  stage, 
by  pressure  applied  to  the  joints.  This  is  accomplished  by 
means  of  a  compressed  sponge.  The  joint,  which  is  the  seat 
of  the  disease,  is  covered  with  a  compressed  sponge,  which  is 
retained  in  position  by  means  of  a  roller  bandage.  The  sponge 
is  then  wet  with  warm  water,  which  causes  it  to  gradually  ex- 
pand, and  thus  produce  an  equal  amount  of  pressure  over  all 
the  parts  covered.  The  sponge  is  applied  once  or  twice  a  day, 
as  the  case  may  demand. 

To  remove  the  fluid,  simple  aspiration,  followed  by  elastic 
pressure,  suffices  in  most  cases,  but  where  simple  aspiration 
does  not  succeed,  Dr.  Sayre  removes  the  fluid  by  means  of 
the  ordinary  trocar,  and  then  injects  the  cavity  with  Lugol's 
solution  of  iodine.  After  this  operation,  the  patient  is  placed 
in  bed,  the  knees  firmly  bandaged,  locked  in  a  perfectly 
immovable  apparatus,  and  elevated  above  the  rest  of  the 
body.  Ice-bags  are  employed,  if  necessary,  so  as  to  keep 
down  inflammatory  action. 

This  disease  is  treated  at  the  Roosevelt  Hospital  by  leeches 
applied  over  the  diseased  joint. 

CANCER  OF  THE   LOWER   LIP. 

Dr.  Sayre  removes  these  growths  at  once,  with  a  knife. 
He  avoids  hemorrhage  by  having  an  assistant  make  pressure 
upon  the  facial  arteries,  as  they  pass  over  the  ramus  of  the 
lower  jaw.  The  wound  is  closed  by  means  of  sutures,  or 


Surgical  and  Venereal  Diseases.  61 

pins  with  the  figure-of-eight  suture.  Pins  are  most  frequently 
used,  and  are  passed  through  the  lips  of  the  wound,  whose 
edges  are  then  brought  together  in  such  a  manner  as  to  avoid 
leaving  any  notch  in  the  free  margin  of  the  lip.  The  attach- 
ments of  the  cheek  are  loosened  with  the  knife,  if  necessary, 
in  order  to  give  more  opportunity  for  perfect  adjustment. 
Two  pins  have  usually  sufficed.  After  the  pins  are  adjusted, 
and  the  sutures  twisted  about  them,  a  piece  of  adhesive  plaster 
is  placed  beneath  the  point  of  the  pins,  to  prevent  irritation 
and  excoriation.  Then  long,  narrow  strips  of  adhesive  plas- 
ter are  adjusted  so  as  to  give  support  to  the  pins  in  holding 
the  lips  of  the  wound  in  co-aptation.  These  strips,  passing 
above  and  below  each  pin,  are  carried  far  back  upon  the  sides 
of  the  face  and  neck.  The  pins  are  removed  within  48  hours, 
at  most,  after  the  operation.  They  are  removed  by  seizing 
them  at  the  head  with  a  pair  of  pincers  and  carefully  turning 
them  round  once  or  twice,  before  making  the  least  traction. 
In  this  way,  the  pins  are  withdrawn  without  disturbing  the 
threads  or  plasters,  which,  together  with  the  crusts,  are  left 
remaining,  and  are  not  removed  for  some  time. 

INGROWING  TOE-NAILS. 

Immense  relief  has  been  afforded  in  these  cases,  by  Dr. 
Sayre,  by  applying  a  few  threads  of  cotton  beneath  the  cut- 
ting edge  of  the  nail,  in  such  a  manner  as  to  protect  the 
excessively-tender  tissues  from  the  irritation  produced  by 
being  brought  into  close  contact  with  it.  This  cotton  is 
applied  by  means  of  a  narrow,  thin-bladed  knife,  without 
cutting  edge.  With  this  instrument,  he  draws  a  few  threads 
of  cotton  down  between  the  nail  and  the  mass  of  granula- 
tions, and  so  on  until  they  are  carried  beneath  the  cutting 
edge  of  the  nail.  After  placing  the  threads  in  situ,  the  fung- 
ous granulations  are  penciled  over  freely  with  nitrate  of  silver. 
This  application  is  repeated  as  often  as  the  destroyed  tissues 
separate,  until  the  exuberant  growth  is  all  destroyed. 


62  Notes  of  Hospital  Practice. 

INFLAMMATION   OF  THE  WRIST-JOINT. 

The  indications  consisting  in  placing  the  joint  perfectly  at 
rest,  and  at  the  same  time  removing  all  pressure  from  the 
articular  surfaces,  Dr.  Sayre  proceeds  as  follows :  He  takes 
a  piece  of  sole-leather,  long  enough  to  half  or  two-thirds 
surround  the  arm.  This  is  then  dipped  in  cold  water,  and 
made  thoroughly  flexible.  It  is  then  covered  with  a  piece  of 
adhesive  plaster,  plaster  side  out,  long  enough  to  go  com- 
pletely round  it,  lengthwise.  Each  opening  is  then  covered 
Avith  a  piece  of  oakum.  The  leather-lined  plaster  he  now 
applies  to  the  palm  of  the  hand,  moulding  it  and  securing  it 
with  a  roller  bandage,  as  far  as  the  wrist.  Grasping  the  hand 
already  covered,  while  an  assistant  grasps  the  arm  near  the 
elbow,  he  makes  extension  and  counter-extension,  until  the 
patient  says  that  all  pain  is  relieved,  and  then  brings  the 
remainder  of  the  leather- lined  plaster  against  the  forearm, 
and  secures  it  with  a  continuation  of  the  bandage.  In  this 
manner,  all  pressure  is  removed  from  the  articular  surfaces, 
pain  is  relieved,  and  an  apparatus  is  afforded  which  retains 
everything  at  perfect  rest. 

FISTULA  IN  ANO. 

Several  cases  of  this  disease  have  been  treated  in  the  wards 
of  the  Roosevelt  Hospital  by  means  of  the  elastic  ligature,  and 
the  patients  have  suffered  but  little  inconvenience  while  the 
ligature  was  cutting  through.  They  were  up  and  about  most 
of  the  time,  and  suffered  but  little  pain.  In  one  case  the 
ligature  cut  its  way  through  in  five  days;  in  two  other  cases, 
in  seven  days,  and  in  every  case  a  fine  granulating  surface 
was  left  behind,  which  healed  much  more  readily  and  satisfac- 
torily than  the  wound  made  by  the  knife. 

EMPYEMA. 

The  treatment  uursued  at  the  Roosevelt  Hospital,  in  cases 


Surgical  and  Venereal  Diseases.  63 

of  this  disease,  is  by  free  incision  through  the  chest  wall.  The 
pleural  cavity  is  then  washed  out  with  a  solution  of  salicylic 
acid,  of  the  strength  of  1  part  to  500  of  water.  If  the  open- 
ing shows  a  tendency  to  close  at  any  time,  it  is  dilated  with 
sponge-tents. 

BORACIC   ACID   AS  AN   ANODYNE. 

Pain  in  and  about  the  wound,  subsequent  to  removal  of  the 
breast  for  scirrhus,  is  allayed,  at  St.  Luke's  Hospital,  by  ap- 
plying cloths  which  have  been  wet  in  a  solution  of  boracic 
acid. 

SILICATE   OF   LIME  SPLINT. 

This  splint  is  obtained  by  using  a  saturated  solution  of 
chloride  of  lime  and  the  silicate  of  soda.  It  is  supposed  that 
a  chemical  decomposition  occurs  between  the  two  articles, 
which  gives  rise  to  silicate  of  lime.  The  apparatus  is  made 
in  the  following  manner:  First  apply  a  bandage  which  has 
been  soaked  in  the  solution  of  lime  and  then  squeezed  very 
nearly  dry  ;  next  give  the  bandage  applied  a  coating  of  silicate 
of  soda ;  then  apply  another  bandage  wet  in  the  lime  solution 
and  follow  it  with  a  coating  of  the  soda.  Thus  go  on  until 
the  requisite  number  of  bandages  are  applied.  The  splint, 
when  dry,  is  much  harder  than  the  silicate  of  soda  splint.  It 
is  much  lighter  than  a  plaster  splint,  and  has  given  general 
satisfaction  at  Bellevue  Hospital. 


SURGICAL   DRESSING. 

The  dressing  has  been  found,  at  Bellevue  Hospital,  to  be 
a  valuable  one  for  all  granulating  surfaces. 

R     Baeilicon  ointment %j. 

Balsam  of  Peru jj.  M. 

SlCK — Apply,  spread  upon  lint. 


64  Notes  of  Hospital  Practice. 

BURNS. 

At  Bellevue  Hospital  burns  are  coated  with  mucilage  of 
gum  arable  and  are  then  dusted  with  lycopodium.  As  soon 
as  any  of  this  dressing  falls  off  it  is  re-applied.  In  other  in- 
stances, a  solution  of  the  nitrate  of  silver  (gr.  xx  to  the  ounce) 
is  employed.  In  some  cases,  solutions  as  strong  as  gr.  xl  to 
the  ounce  have  been  employed  with  benefit.  The  solution  is 
applied  with  a  camel's-hair  brush,  and  the  surface  is  left  ex- 
posed to  the  influence  of  light  and  air.  The  solution  is  re- 
newed whenever  fissures  occur  in  the  coating  thus  formed. 

ANTHRAX. 

A  very  simple  and  efficient  method  of  management  has 
been  adopted  at  Bellevue  Hospital.  A  broad  piece  of  spongio- 
piline  is  chosen  and  a  hole  cut  through  it  large  enough  to 
receive  the  apex  of  the  tumor.  It  is  then  applied,  and  the 
anthrax  let  alone. 

ABSCESSES 

At  Bellevue  Hospital  are  at  first  injected  with  a  solution  con- 
sisting of  equal  parts  of  water  and  tincture  of  iodine.  This 
solution  is  gradually  increased  in  strength  until  pure  tincture 
of  iodine  is  employed. 

t 

INTERNAL    HAEMORRHOIDS. 

Dr.  Erskine  Mason  divides  treatment  into  medical  ana 
surgical.  The  aperients  which  he  considers  most  valuable  are 
the  salines  in  combination  with  sulphur,  or  a  pill  composed 
of  taraxacum  and  aloes. 

As  regards  the  employment  of  nitric  acid,  he  thinks  that 
its  use  should  be  confined  solely  to  those  vascular  spots  of 
mucous  membrane  which  are  sometimes  seen  in  connection 


Surgical  and  Venereal  Diseases.  65 

with  other  tumors,  and  to  the  small,  florid,  sessile  growths, 
which  so  readily  bleed  upon  the  slightest  touch.  The  acid 
which  he  employs  in  such  cases  is  of  the  strongest  kind.  The 
parts  are  dried  and  then  touched  lightly  with  a  piece  of  wood 
dipped  in  the  acid,  avoiding  the  surrounding  mucous  mem- 
brane. The  parts  are  then  oiled  and  returned.  One  or  two 
applications  generally  suffice. 

In  some  cases  Dr.  Mason  employs  the  clamp  and  actual 
cautery.  He  grasps  the  pile  with  forceps,  or  tenaculum, 
drags  it  down,  and  strongly  compresses  it  by  means  of  a  clamp 
around  its  base.  The  pressure  is  maintained  by  means  of  a 
screw.  He  then,  with  a  pair  of  curved  scissors,  clips  off  the 
pile,  a  short  distance  from  the  clamp,  so  as  to  leave  a  stump, 
over  which  an  iron  heated  to  a  dull  heat  is  drawn. 

He  regards  the  ligature  as  the  safest  and  most  efficient 
means  of  treating  piles.  He  employs  a  moderately  fine, 
waxed,  silk  ligature,  or  one  of  linen.  After  seizing  the 
tumor  and  dragging  it  down,  he  surrounds  it  with  the  ligature, 
ties  it  tightly  in  two  knots,  and  cuts  it  off  a  little  distance 
from  the  knot.  He  is  careful  not  to  tie  the  ligature  close  up 
to  the  base  of  the  tumor,  and  so  avoids  including  the  coats  of 
the  intestine  and  consequent  troublesome  contraction  of  the 
bowels. 

He  regards  with  great  favor  Mr.  Allingham's  method  of 
treating  internal  hemorrhoids  which  consists  in  separating  the 
pile,  with  the  scissors,  from  its  attachment  to  the  muscular 
and  other  tissues  of  the  bowel  beneath  its  mucous  membrane. 
The  cut  is  carried  up  for  a  little  distance  parallel  to  the  wall 
of  the  bowel  and  the  neck  of  the  tumor  is  then  ligated.  In 
this  way  little  more  than  the  vessels  which  form  it  are  tied  • 
and  there  being  less  tissue  for  the  ligature  to  separate,  it  comes 
away  sooner.  The  vessels  running  parallel  to  the  incision  are 
not  likely  to  be  wounded,  and  if  there  is  any  bleeding  point  it 
is  readily  seen  and  can  be  tied  at  once.  The  wound,  being  an 
incised  one,  readily  heals.  After  this  operation  the  patient  is 
confined  in  bed  for  at  least  a  week.  Dr.  Mason  is  in  the  habit 


66  Notes  of  Hospital  Practice. 

not  only  of  having  the  anus  frequently  bathed  with  warm 
water,  but  also  irrigates  the  parts  with  tepid  water  and  a  little 
carbolic  acid  by  means  of  a  small  syringe.  Immediately  after 
the  operation  a  pad  of  picked  lint  is  placed  over  the  anus  and 
held  in  position  by  a  tight  T  bandage. 


WET   STRAPPING. 

It  is  regarded  at  Bellevue  Hospital  as  an  item  of  some  im- 
portance in  the  treatment  of  old  ulcers,  such  as  are  of  specific 
nature,  found  upon  the  lower  extremities,  that,  if  strapped,  the 
plaster  should  be  permitted  to  remain  as  long  as  possible  with- 
out change.  With  this  object  in  view  several  cases  have  been 
dressed  with  what  have  been  called  wet  straps,  which  are  pre- 
pared by  passing  strips  of  adhesive  plaster  through  hot  water 
instead  of  heating  them  in  the  usual  manner.  In  these  instances 
the  water  is  also  carbolized. 

It  seems  quite  certain  that  the  ulcers  heal  more  rapidly 
under  this  plan  of  treatment  than  any  which  has  been  adopted, 
and  that  the  plaster  does  not  get  loose  as  quick  as  when  heated 
over  a  spirit  lamp. 

ECZEMA   RUBRA. 

A  number  of  cases  of  this  disease  as  occurring  in  the  wards 
of  Bellevue  Hospital  have  followed  facial  erysipelas,  and,  after 
trying  all  the  remedies  ordinarily  resorted  to  in  the  treatment 
of  this  affection  without  benefiting  the  patient,  tincture  iodine 
was  painted  over  the  entire  surfaace.  As  a  result,  the  disease 
was  in  every  way  aggravated  for  one  or  two  days,  but  when 
the  artificial  irritation  subsided,  the  change  produced  in  tissues 
by  the  iodine  permitted  the  cases  to  go  on  to  rapid  and  com- 
plete recovery. 

DOUBLE   OOLLES'   FRACTURES 

Are  dressed  at  Bellevue  Hospital  with  straight  board  spliuta 


Surgical  and  Venereal  Diseases.  67 

6  or  8  inches  long,  the  anterior  splint  reaching  down  to  the 
joint,  the  posterior  1,  2  or  3  inches  upon  the  dorsum  of  the 
hand.  These  splints  are  then  secured  with  roller  bandage. 
Passive  motion  is  begun  at  the  end  of  the  third  week. 


THE  TREATMENT  OF  FRACTURES  AT  THE  NEW  YORK 
HOSPITAL,. 

Cotles'  Fracture. — The  Morris  treatment  is  that  generally 
pursued.  Two  bandages,  3  inches  in  width  and  rather  loosely 
rolled,  are  placed  on  either  surface  of  the  forearm,  over  the 
seat  of  fracture,  and  maintained  in  place  by  a  broad  strip  of 
adhesive  plaster,  making  sufficient  compression  to  keep  the 
fragments  in  position. 

Fracture  of  the  Patella. — Tilford's  strap-and-buckle  appara- 
tus is  applied.  After  union  has  taken  place  an  elastic  knee- 
cap is  used. 

Fractures  of  the  Tibia  and  Fibula. — The  fracture-box  is 
first  employed  and  followed  by  the  plaster-of-paris  bandage. 

Fractures  of  the  Femur  are  treated  either  with  the  plaster- 
of-paris  splint,  or  with  Buck's  extension  apparatus,  with  Volk- 
man's  sliding  contrivance  for  keeping  the  foot  straight,  and 
ordinarily  a  long  external  splint. 


EPIDIDYMITIS. 

When  a  case  of  gonorrhoea  presents  itself  at  Bellevue  Hos- 
pital the  patient  is  made  to  wear  a  suspensory  bandage.  This 
bandage  may  prevent  swelling  of  the  testicle.  When  the 
epididymitis  occurs  in  spite  of  the  bandage  and  is  seen  early, 
if  the  pain  is  severe,  needle  punctures  are  made  in  the  tunica 
vaginalis,  and  the  hydrocele,  which  causes  the  pain,  thus 
relieved.  As  a  rule  it  has  not  been  found  advisable  to  use 
urethral  injections  during  the  acute  stage  of  epididymitis.  In 
this  stage  sedative  lotions,  fomentations,  leeches,  and  cold 


68  Notes  of  Hospital  Practice. 

applications  are  employed.  Rest  in  bed  is  insisted  upon.  If 
leeches  are  used  they  are  applied  along  the  course  of  the 
spermatic  cord.  The  testicles  are  supported  by  passing  a 
broad  strip  of  adhesive  plaster  under  the  scrotum  and  from 
one  thigh  to  the  other. 

THE  TRANSPLANTATION   OP  SKIN. 

Dr.  H.  D.  Noyes  lays  great  stress  upon  the  observance  of 
the  following  rules : 

First.  The  piece  of  skin  used  must  be  dissected  so  as  to  be 
entirely  free  from  subcutaneous  connective  tissue  and  fat. 

Second.  The  piece  of  skin  should  not  be  secured  in  position 
by  means  of  sutures,  but  by  co-aptation  with  gold-beater's 
skin,  or  such  means  as  maintain  absolute  immobility  during 
the  entire  process  of  union. 

Third.  There  must  be  expected  an  extraordinary  contrac- 
tion when  the  piece  of  skin  is  separated  from  its  surroundings. 

ACUTE,   NON-SPECIFIC   URETHRITIS. 

Rest,  and  30  grains  of  the  citrate  of  potassium  three  times 
a  day,  is  the  treatment  generally  pursued  witli  success  by  Dr. 
Gouley. 

PERINEAL   FISTULA. 

Firm  pressure  is  made  with  the  finger,  placed  either  in  the 
rectum  or  at  the  point  of  the  internal  orifice  of  the  fistula, 
every  time  that  the  patient  urinates,  in  order  that  the  urine 
may  pass  through  the  urethra,  and  none  escape  into  the  fistu- 
lous  tract.  In  this  way,  Dr.  Gouley  gives  the  fistula  an  oppor- 
tunity of  healing  up  by  granulation,  without  having  the  pro- 
cess interfered  with  by  the  passage  of  urine  over  the  surface. 

'  '"Sv 

CHANCRE. 

When  a  well-determined  initial  lesion  is  situated  in  looso 


Surgical  and  Venereal  Diseases.  69 

tissue,  Dr.  F.  N.  Otis  excises  it  as  early  as  possible.  The 
infective  neoplasm  he  removes  entire.  He  performs  the  opera- 
tion of  incision  in  the  following  manner:  The  parts  are 
first  thoroughly  cleansed  by  gentle  bathing  in  warm  water 
In  all  open  legions,  a  solution  of  carbolic  acid,  of  the  strength 
of  1  part  of  the  acid  to  40  parts  of  water,  is  applied,  after 
which,  the  indurated  mass  is  raised  between  the  forefinger 
and  thumb,  and  encircled  firmly  at  the  base  with  a  bit  of  fine 
silver  or  malleable  iron  wire.  Then,  with  a  narrow,  sharp- 
pointed  bistoury,  the  tissues  are  pierced  at  the  centre,  beneath 
the  compressing  wire,  or  probe,  and  cut  well  under  and  out, 
including  all  the  indurated  and  a  little  of  the  sound  tissue  of 
that  side.  The  same  cut-out  is  then  made  on  the  opposite 
side.  After  every  portion  of  the  neoplasm  is  removed,  inter- 
rupted sutures  of  silk,  or  silver  wire,  are  then  introduced  at 
intervals  of  one-fourth  of  an  inch.  The  patient  is  kept  in 
the  recumbent  position,  the  parts  being  occasionally  wet  with 
carbolated  water,  until  the  third  day,  when  union  by  first 
intention,  is  usually  found  to  have  taken  place. 

When  excision  is  unadvisable  by  reason  of  the  location  of 
the  indurated  papule,  it  is  subjected  to  applications  of  the 
oleate  of  mercury  (six  per  cent,  solution),  or  a  mild  mercurial 
ointment,  is  employed.  When  the  mucous  membrane  cover- 
ing the  induration  is  abraded,  it  is  dusted  with  dry  calomel 
and  protected  with  a  thin  layer  of  dry  lint.  Calomel,  in 
combination  with  lime-water,  in  the  proportion  of  a  drachm 
to  a  pint,  or  half  a  drachm  of  the  bichloride  of  mercury,  are 
much  esteemed  by  Dr.  Otis  as  topical  applications.  Calomel, 
in  some  form  or  other,  is  always  administered  internally. 

The  mucoid  Chancre  is  treated  by  the  application  of  the 
solid  nitrate  of  silver. 

The  inflamed,  or  suppurative  initial  lesion  is  treated  by  rest 
and  some  sedative  dressing  such  as  the  lotio  plumbi  et  opii,  in 
a  5-grain  solution,  or  the  simple  powdered  iodoform,  or  iodo- 
forin  with  an  equal  part  of  taunic  acid. 

The  gangrenous  form  is  managed  by  poultices  of  powdered 


70  Notes  of  Hospital  Practice. 

charcoal,  and  by  the  internal  administration  of  mercury 
Where  the  patient  is  debilitated  or  scrofulous,  generous  diet, 
quinia  and  iron  are  necessary. 

Concealed  initial  lesions  are  treated  with  bougies  or  supposi- 
tories, medicated  with  opium,  salicylic  acid,  or  iodoform. 


THE  CHANCROIDAL   UL.CER. 

Here  are  some  formulae  which  Dr.  Sturgis  recommends  for 
local  application  : 

1.  R     Pulv.  iodoformi  ..........................................  1  part. 

Lycopodii  ..................................................  2  parts.        M. 

Triturate  well,  apply  locally. 

2.  R     Pulv.  iodoformi, 

Pulv.  acid  tan  .............................................  p.  oe.  M. 

Triturate  and  use  locally. 

3.  R     Pulv.  iodoformi  ..........................................   5J. 

Tinci  sulphat  .............................................   gr.  v. 

Pulv.  acid,  tan  ............................................  ^  j.  M. 

Triturate.     For  local  use. 


4.      R     Acid,  carbol.  cryst 
Aquae 


Or, 

5.  R     Zinci  sulphat  .............................................  gr.  v-xx. 

Aquae  ........................................................  f£  ij.  M. 

6.  R     Acid,  nitric!  ...............................................  f^ss. 

Aquae 


As  agents  destructive  of  the  chancroidal  ulcer  Dr.  Sturgis 
employs  (1)  the  white  iron,  or  the  galvano  cautery,  (2)  strong 
sulphuric  acid,  (3)  chemically-pure  nitric  acid,  (4)  pure  carbolic 
acid.  He  very  generally  applies  sulphuric  acid  in  the  shape 
of  Ricord's  carbo-sulphuric  paste,  which  is  made  by  taking  a 
small  quanity  of  finely-powdered  tvillow  charcoal,  and  enough 


Swrgical  and  Venereal  Diseases.  71 

of  the  acid  to  make  a  paste  of  the  consistence  of  thick  cream. 
This  is  put  on  with  a  porcelain  or  glass  spatula,  care  being 
taken  to  carry  the  agent  into  sound  tissue  both  beneath  and 
on  the  surface  of  the  edges  of  the  chancroid. 

Salicylic  acid  is  first  sprinkled  over  the  sore  at  the  New 
York  Hospital,  and  then  the  following  wash  applied : 

\ 

R     Acid  salicyl., 

Sodii  borat aa    gr.  xr. 

Glycerinae ij^  j.  M. 


THE  TREATMENT  OF  HEMORRHOIDS. 

For  the  purpose  of  effecting  a  radical  cure,  piles  are  treated 
at  Bellevue  Hospital  with  the  double  ligature.  The  sphincter 
is  not  dilated.  Treatment  after  the  operation  is  believed  to  be 
sufficient  to  prevent  spasm  of  the  sphincter.  In  cases  in  which 
the  pile  can  be  easily  surrounded,  Sims'  speculum  is  recom- 
mended. The  operation  being  completed,  a  suppository  con- 
taining opium  and  belladonna  is  introduced  well  above  the 
internal  sphincter.  A  large  piece  of  lint  smeared  with  vase- 
line is  then  placed  over  the  anus  and  the  cleft  of  the  nates, 
and  the  cleft  packed  with  cotton  until  it  is  filled  to  a  level  with 
the  tuber  ischii ;  over  that  a  compress  is  placed,  and  the  whole 
is  retained  in  position  by  means  of  an  ordinary  T  bandage. 

But  if  hemorrhage  occurs  from  the  stump  of  the  pile  or  else- 
where, a  plan  of  treatment  is  recommended,  which  although 
not  new,  is  perhaps  worthy  of  description.  Of  course,  effort 
is  made  to  tie  the  bleeding  vessel.  But  the  plan  recommended 
as  the  better  one  is  first  to  take  a  cone-shaped  piece  of  sponge, 
and  make  it  hollow ;  then  to  pass  a  thread  from  the  inside 
through  the  side  of  the  sponge,  over  the  apex  of  the  cone,  and 
return  it  to  the  cavity  in  the  sponge.  In  that  manner  a  loop 
is  made  which  places  the  sponge  within  the  control  of  the  sur- 
geon. The  sponge  is  to  be  slightly  moistened,  compressed,  and 
pushed  up  as  high  as  possible  in  the  rectum  upon  the  tip  of 


72  Notes  of  Hospital  Practice. 

the  finger.  Pieces  of  lint  are  then  carried  in  until  the  cavity 
in  the  sponge  is  filled.  As  soon  as  filled,  traction  is  made 
upon  the  strings,  when  the  sponge  will  spread  out  and  press 
against  the  sides  of  the  rectum.  In  this  manner  the  flow  of 
blood  upward  is  prevented,  and  the  compress  already  described 
prevents  any  discharge  from  the  anus.  In  ordinary  cases  it  is 
thought  advisable  to  leave  the  sponge  in  situ  for  36  or  48 
hours.  If  hemorrhage  returns,  the  sponge  is  replaced. 


ACUTE   RETENTION   OF  tJRINE. 

A  safe  rule,  therefore,  for  guidance  HI  the  management  of 
cases  of  acute  retention  of  urine  of  forty-eight  hours'  duration, 
which  Dr.  Gouley  lays  down  is,  never  to  draw  off  more  than 
one-third  of  the  contents  of  the  bladder,  and  to  do  this  very 
slowly  by  half  closing  the  distal  end  of  the  catheter,  so  that 
the  urine  will  flow  m  a  very  small  stream.  Having  collected 
half  a  pint,  Ive  closes  the  catheter  for  a  quarter  of  an  hour, 
then  lets  another  'half  pint  flow,  and  so  on,  until  the  required 
quantity  has  been  obtained.  In  two  hours  he  repeats  the 
catheterism,  if  the  first  has  been  easy — otherwise,  the  catheter 
is  closed,  and  left  in  for  tw<enty-four  hours — and  removes 
again  the  same  quantity  very  gradually,  and  at  the  -expiration 
of  another  period  of  two  hours  completely  empties  the  blad- 
der, always  slowly;  and  in  this  way  he  takes  the  necessary 
precautions  to  avoid  'both  cystorrhagia  and  polynria.  Every 
three  hours  after  the  last  catheteriara  the  urine  is  drawn  off 
until  the  patient  can  pass  it  spontaneously ;  if  he  cannot  do 
so,  the  catheter  is  resorted  to  at  such  intervals  as  are  found 
necessary.  Dr.  Gouley  also  finds  it  necessary  to  treat  the  ex- 
isting vesical  inflammation  and  atony.  For  general  medica- 
tion he  recommends  the  tincture  of  chloride-of  iron,  in  5-minim 
doses,  three  times  daily,  and  also  diluent  drinks,  such  as  30 
grains  of  citrate  of  sodkim  or  potassium,  in  half  a  glass  of 
water  three  times  daily,  and  in  a  few  days,  for  a  change,  dog- 
grass  tea,  etc.  Topical-ly,  kmsps  0f  ice  the  size  of  the  last  joint 


Surgical  and  Venereal  Diseases.  73 

of  the  thumb,  are  introduced  into  the  rectum  in  rapid  suc- 
cession as  fast  as  they  melt,  for  an  hour,  night  and  morning. 
A  bag  of  ice  is  afterwards  applied  alternately  to  the  perinseum 
and  hypogastrium  for  an  hour  or  more.  Each  time  that  the 
bladder  is  emptied  by  the  catheter,  a  couple  of  ounces  of  cold 
borax  solution,  from  5  to  10  grains  to  the  ounce,  are  thrown 
in  ami  allowed  to  run  out  slowly,  then  two  more,  and  two 
more  ounces  which  are  left  in  and  the  catheter  withdrawn ; 
this  is  accomplished  in  five  minutes.  Dr.  Gouley  has  found 
that  no  preparation  gives  more  satisfaction  than  the  borax  so- 
lution for  cleansing  bladders  which  contain  offensive  purulent 
urine.  He  thinks  it  is  as  well  to  have  in  readiness  a  strong  so- 
lution of  borax  in  glycerine ;  1  ounce  of  the  biborate  of  sodium 
being  readily  dissolved  by  6  ounces  of  glycerine,  each  drachm 
of  such  a  solution  being  equal  to  10  grains  of  biborate.  In  a 
week,  or  thereabouts,  if  the  case  progresses  well,  the  irriga- 
tions are  diminished  in  number  until  only  one  is  used  each 
day.  In  some  cases  a  mild  faradic  current  has  been  found 
serviceable 

CYSTITIS   FOLLOWING   GONORRHOEA. 

Dr.  Gouley  regards  this  as  a  very  troublesome  affection,  and 
one  which  is  apt  to  last  from  three  to  six  months.  Some  of 
the  French  surgeons,  he  says,  are  in  the  habit  of  treating  it  by 
injecting  5  or  10  minims  of  a  solution  of  nitrate  of  silver,  (30 
or  40  grains  to  the  ounce,)  from  time  to  time,  into  the  blad- 
der; but  personally,  he  prefers  the  internal  treatment  by 
means  of  diluents  and  balsamics.  In  addition,  he  thinks  it 
well  to  give  belladonna,  if  the  drug  is  well  borne,  and  begins 
with  about  J  of  a  grain  three  times  a  day.  In  some  cases, 
even  smaller  doses  than  that  have,  in  his  hands,  sent  the 
pulse  up  to  120,  and  produced  the  most  uncomfortable  symp- 
toms, while  other  patients  can  take  from  2  to  5  grains  a  day 
with  impunity.  In  some  instances  he  is  in  the  habit  of  com- 
bining the  aqueous  extract  of  opium  with  the  belladonna,  (a 


74  Note*  of  Hospital  Practice. 

grain  of  the  one  to  £  of  a  grain  of  the  other,)  and  sometime* 
he  finds  that  rectal  suppositories  containing  these  ingredients 
act  very  admirably. 

'CYSTORRHAGIA. 

As  a  preventive  treatment  of  cystorrhagia,  and  in  cases  of 
over-distention  of  the  bladder,  Dr.  J.  W.  S.  Gouley  teaches 
that  the  bladder  should  be  emptied  very  gradually  in  the 
course  of  from  12  to  72  hours.  This  is  accomplished  by  the 
introduction  of  a  soft  catheter,  which  is  secured  in  position, 
and  the  urine  then  allowed  to  trickle  through  it  slowly,  by 
partially  obstructing  the  distal  orifice  with  a  finger,  so  that, 
in  the  course  of  five  or  six  minutes,  not  more  than  eight 
ounces  will  have  escaped.  This  process  is  repeated  every  two 
hours,  until  the  bladder  is  empty.  If  the  urine  drawn  is 
very  foetid,  the  process  is  modified  as  follows:  Immediately 
after  drawing  the  first  half  pint  of  urine,  eight  ounces  of 
warm  water,  in  which  has  been  dissolved  a  scruple  of  bibo- 
rate  of  soda,  are  injected  into  the  bladder,  then  a  pint  of  urine 
drawn,  and  immediately,  half  a  pint  of  borax  solution  thrown 
in.  This  procedure  is  repeated  six  or  eight  times,  at  the  first 
sitting,  or  until  the  whole  of  the  offensive  urine  is  gotten  rid 
of,  and  the  bladder  contains  nothing  but  the  clear  borax  solu- 
tion ;  then,  every  two  hours,  and  in  some  cases,  even  every 
three  hours,  half  a  pint  of  the  fluid — now  mixed  with  newly- 
secreted  urine — is  drawn  off,  until  the  bladder  is  completely 
empty.  In  this  way,  a  bland  fluid  is  substituted  for  decom- 
posed and  irritating  urine,  the  hydrostatic  pressure  will  not 
have  been  removed  too  suddenly,  and  cystorrhagia  is  pre- 
vented. 

When  cystorrhagia  has  taken  place,  besides  enjoining  abso- 
lute rest,  in  the  horizontal  posture,  Dr.  Gouley  takes  means 
to  prevent  the  bladder  from  becoming  distended  with  bloody 
urine.  If  he  finds  hypogastric  dullness  extending  to  or  into 
the  umbilical  region,  he  draws  off,  through  a  gum  catheter, 
only  a  pint  of  urine,  then  throws  in  half  a  pint  of  the  borax 


Surgical  and  Venereal  Diseases,  75 

solution,  and  draws  half  a  pint  of  fluid,  and  repeats  the  pro- 
cess until  the  fluid  becomes  clear,  or  nearly  so.  Afterwards, 
every  hour  or  two  hours,  the  stopper  of  the  catheter  is 
removed,  and  half  a  pint  of  fluid  allowed  to  flow,  until  the 
Madder  is  completely  empty.  The  catheter  is  retained  in 
position  for  24  hours.  The  hemorrhage  is  checked  by  occa- 
sionally throwing  into  the  bladder  two  or  three  ounces  of  a 
weak  solution  of  tannin,  or  of  alum.  Dr.  Gouley  has  also 
found  ice  in  the  rectum  a  valuable  adjuvant. 

He  treats  hemorrhages  caused  by  papillomatous  or  cancer- 
ous tumors,  by  the  exhibition  of  ergot,  in  the  shape  of  from 
"H^xv-xx  of  the  fluid  extract,  given  every  two  or  three  hours, 
or  else  he  uses  gallic  acid  dissolved  in  glycerine,  or  quinia 
with  an  equal  quantity  of  dilute  sulphuric  acid,  or  tincture 
of  the  chloride  of  iron,  etc.  The  dose  is  reduced  and  alto- 
gether discontinued,  as  SOOD  as  possible,  so  as  to  save  the 
digestive  organs. 

When  no  fluid  runs  through  the  catheter,  after  it  has  been 
properly  introduced,  owing  to  the  fact  that  a  clot  has  become 
impacted  in  the  catheter,  Dr.  Gouley  removes  the  catheter 
and  washes  it  out,  or  takes  a  clean  catheter  and  introduces  it. 
But  when  the  bladder  is  filled  with  clotted  blood,  he  uses  a 
soft  catheter,  with  one  large  eye,  or  a  metallic  Mercier  cathe- 
ter, as  large  as  can  be  introduced,  and  iiyects  one  or  two 
ounces  of  warm  borax  .solution.  If  nothing  flows,  the  instru- 
ment is  moved  gently  to  and  fro,  and  rotated  to  the  right  and 
left,  so  as  to  break  up  the  clots.  Aspiration  is  then  made, 
either  with  a  syringe  or  with  Bigelow's  rubber  bag.  Not 
more  than  three  or  four  ounces  of  clots,  or  gmmous  clots,  are 
aspirated  at  a  time.  Alternate  injections  and  aspirations  are 
made  at  the  same  sitting. 


THE   MEDICAL   AND  SURGICAL  DISEASES   OF 
WOMEN. 


VAGINISMUS. 

Dr.  T.  G.  Thomas  treats  this  condition  as  follows :  First, 
the  patient  is  thoroughly  anaesthetized  with  ether,  and  then 
*>ach  labium  majus  is  held  back  by  an  assistant.  The  parts 
being  thus  exposed,  the  hymen  is  seized  with  a  pair  of  mouse- 
toothed  forceps,  and  snipped  completely  out  with  the  scissors, 
which  are  preferable  to  the  knife  for  this  purpose.  The 
sponge  is  usually  all  that  is  necessary  to  stop  the  bleeding. 
The  entrance  of  the  vagina  is  then  cut  down  upon  and  en- 
larged, and  while  this  is  being  done  the  assistants  are  instructed 
to  stretch  the  vagina  well  on  either  side.  The  incisions  are 
made  into  the  perinaBal  body,  but  not  through  any  muscle. 
Three  incisions  are  all  that  Dr.  Thomas  finds  necessary.  Of 
these,  one  is  in  the  median  line,  and  one  on  either  side.  One 
of  Sims'  plugs  is  then  pushed  into  the  vagina  and  held  in 
place  by  means  of  a  broad  strip  of  adhesive  plaster  passing 
from  the  lower  part  of  the  back,  over  the  perinseum  and  up  to 
the  abdomen,  with  a  hole  cut  in  it  for  passing  a  catheter. 
The  plug  puts  an  end  to  all  hemorrhage,  and  is  generally  left 
in  position  for  three  or  four  days  before  being  disturbed.  At 
the  end  of  that  time,  it  is  taken  out  so  as  to  permit  the  vagina 
to  be  thoroughly  syringed  with  warm  water.  It  is  then  re- 
placed as  before.  In  a  week's  time  the  patient  is  able  to  re- 
move it  and  put  it  back  herself.  It  is  to  be  worn  for  three 
weeks  or  more  constantly,  then  it  is  only  necessary  to  wear  it 
at  night.  In  the  course  of  a  month  or  six  weeks,  Dr.  Thomas' 
patients  are  able  to  dispense  with  it  altogether. 

(76) 


Medical  and  Surgical  Diseases  of  Women.  77 

LABOR   IN  KYPHOTIC  PELVES. 

Dr.  Isaac  E.  Taylor  reaches  the  following  conclusions: 

1.  A  mutilated  child  can  be  delivered  with  safety  to  the 
mother  through  a  space  of  If  inches  antero-posterior,  and  2J 
to  3  inches  transverse  diameter,  by  craniotomy,  cephalotripsy, 
or  cranioclasm.     When  the  vault  has  been  destroyed,  the  face 
is  made  to  present  edgewise,  or  the  head  gidewise. 

2.  After  cephalotripsy,  or  cranioclasm,  if  necessary,  version 
with  propulsion  from  above  the  pubes,  performed  early  and 
before  the  uterine  forces  are  exhausted,  is  preferable  to  that 
just  indicated. 

3.  The  cephalotribe,  or  cranioclast,  cannot  be  considered  as 
available  tractors  in  cases  of  extreme  contraction  of  the  pelvis, 
but  other  instruments  become  necessary  to  properly  eflect  the 
delivery  of  the  woman. 

3.  The  Caesarean  section  should  not  be  performed  when  con- 
traction or  deformity  is  present,  as  stated  above,  unless  de- 
manded by  other  conditions  and  complications. 


LACERATION   OF  THE  PERINEUM. 

Dr.  Montrose  A.  Fallen  urges  immediate~~operative  inter- 
ference, if  possible.  He  enters  iiis  sutures  (silver  wire)  deep, 
and  not  more  than  a  line  apart,  and  supplements  them  by 
superficial  sutures  in  each  inter-space.  The  bowels  are  kept 
soluble  by  warm  enemata,  and  not  constipated  by  opium,  after 
the  common  rule.  The  vagina  is  kept  thoroughly  cleansed, 
the  bladder  well  emptied,  and  the  nates  of  the  patient  are 
placed  in  an  india-rubber  ring  cushion  filled  with  air. 


MENORRHAGIA. 

Dr.  Barker  directs  his  patients  to  use  for  a  week  previous 
to  the  expected  period,  the  following  suppositories: 


78  Notes  of  Hospital  Practice. 

R     Ext.  ergot,  aq.  (Squibb) 9ij. 

Cacao  butter jj.  M. 

Et  in  suppos.  No.  xij  div. 
SlG. — One  to  be  introduced  into  the  rectum  morning,  noon  and  night. 

These  suppositories  are  carried  as  far  as  possible  up  into  the 
bowel,  and  the  patient  directed  to  remain  in  a  recumbent  posi- 
tion for  at  least  an  hour  after  using  them. 

In  cases  of  irregular  uterine  hemorrhage  seen  in  connection 
with  the  climacteric  period  he  introduces  into  the  cavity  of  the 
uterus  cylinders  of  iodoform  made  according  to  this  formula  : 


R     Iodoform 

Gum  tragacanth gr.  xv. 

Mucil q.  s.  M. 

Et  div.  into  cylinders  No.  x,  each  one  and  one-half  inches  in  length. 

One  of  these  cylinders  is  directed  to  be  carried  completely 
into  the  cavity  of  the  uterus,  and  a  pledget  of  cotton  is  placed 
against  the  cervix  to  retain  it  in  position.  One  of  these  cylin- 
ders is  introduced  daily  for  five  or  six  days  previous  to  men- 
struation. 

POST-PARTUM   HEMORRHAGE. 

When  this  is  due  to  inertia  of  the  uterus,  Dr.  Montrose  A. 
r*allen  introduces  the  hand  into  the  cavity  and  removes  the 
clot,  then  incites  contractions  of  the  organ  by  manual  pressure, 
and  administers  stimulants  and  ergot  hypodermically. 

Where  consequent  to  laceration  of  the  cervix  uteri,  the  tampoh 
is  used  and  stitches  are  necessary. 

PRURITUS  VULVJE  DUE  TO  VAGINAL  LEUCORRHCEA. 

Dr.  Thomas  recommends  frequent  vaginal  injections  of  the 
biborate  of  sodium  in  solution,  and  once  or  twice  a  week  he 
cleanses  the  cervix  thoroughly  of  mucus  and  applies  the 
nitrate  of  silver.  Occasionally  he  uses  chemically-pure  nitric 


Medical  and  Surgical  Diseases  of  Women.  79 

moid  with  the  hope  of  altering  the  secretion.  Copious  injec- 
tions of  water  are  continually  used  and  the  patient  is  told  to 
press  a  suppository  of  butter  of  cacao  containing  5  grains  of 
tannic  or  gallic  acid  up  against  the  cervix  twice  daily. 


ABDOMINAL   PREGNANCY. 

Dr.  T.  G.  Thomas  lays  down  the  following  rules  for  the 
management  of  cases  of  abdominal  pregnancy : 

1.  Before  full  term,  if  the  child  is  alive,  its  growth  may  be 
carefully  watched  with  the  hope  of  delivering  a  living  child 
at  the  end  of  the  ninth  month  by  the  operation  of  leparotomy 
and  also  of  saving  the  life  of  the  mother. 

2.  If  the  child  dies  early  in  abdominal  pregnancy,  delay  is 
advisable,  but  it  should  not  be  carried  to  the  extent  of  the 
development  of  hectic  and  septicaemia. 

3.  At  full  term  the  best  rule  is  to  await  the  evidence  of 
constitutional   disturbance,   and   then  meet   its  development 
promptly  by  operative  interference. 

Dr.  Fordyce  Barker  lays  great  stress  (1)  upon  leaving  the 
placenta  in  situ  after  the  operation,  and  (2)  upon  subsequent 
antiseptic  treatment. 

LACERATION   OF  THE   CERVIX   UTERT. 

Dr.  Gillette  has  recently  resorted  to  a  somewhat  novel  me- 
thod of  treating  this  condition.  He  seizes  the  torn  cervix  with 
two  tenacula,  draws  the  lacerated  surfaces  together,  and  then 
slips  over  the  handles  of  the  tenacula  and  around  the  cervix 
an  ordinary  rubber  strap.  This  treatment  is  not  applicable 
of  course,  to  recent  lacerations,  since  in  such  cases  the  band 
constringing  the  cervix  would  prevent  the  discharge  of  the 
Jochia. 

8UBMUCOU8    AND    INTERSTITIAL    FIBROIDS    OF    THE   WOMB. 

Dr.  Thomas  believes  that  enuoleation  and  the  use  cf  ergot 


80  Notes  of  Hospital  Practice, 

are  attended  by  the  great  dangers  of  septicaemia,  peritonitis, 
hemorrhage  and  exhaustion.  He  is,  on  the  other  hand,  con- 
viivced  that  a  policy  of  inactivity  is  by  no  means  always  a  safe 
one.  He  thinks  that  the  various  other  methods  of  treatment 
employed  at  the  present  day,  excision,  torsion,  avulsion,  ecrase- 
ment,  and  the  production  of  sloughing — are  none  of  them  with- 
out objection,  and  offers  in  their  place  the  following  method, 
which  consists  in  seizing  the  most  dependent  and  accessible 
part  of  the  tumor  with  a  strong  Volsella  forceps,  passing  along 
its  sides  the  serrated  scoop  or  spoon-saw,  and  by  a  gentle  pen- 
dulum motion  from  side  to  side,  sawing  through  the  attach- 
ments of  the  tumor  and  forcing  it  entirely  from  its  connection 
with  the  uterus. 

He  claims  the  following  advantages  for  the  instrument : 

1.  The  attachments  are  separated  by  a  saw  which  greatly 
limits  hemorrhage. 

2.  The  shape  of  the  spoon,  convex  without  and  concave 
within,  causes  it  to  follow,  of  its  own  accord,  the  contour  of 
the  tumor  and  at  the  same  time  to  protect  the  uterine  tissue. 

3.  The  highest  attachment  can  be  as  readily  reached  as  the 
lowest. 

4.  The  saw  action  secures  separation  with  rapidity  and  with 
certainty. 

5.  The  spoon-saw  secures  separation  of  the  growth  at  its 
highest  point  of  attachment,  and  leaves  no  particle  to  decom- 
pose. 

In  order  to  determine  the  extent  of  the  attachment  of  a 
tumor,  Dr.  Thomas  uses  &flai  ickalebone  sound.  He  uses  this 
instrument  in  this  way  :  the  index  finger  of  the  left  hand  is 
placed  against  the  most  accessible  part  of  the  tumor,  and  then 
the  sound  is  passed  up  along  the  side  of  the  tumor  until  it  is 
arrested.  The  sound  being  then  withdrawn  with  the  finger 
Btill  upon  it,  is  laid  upon  a  sheet  of  paper,  and  beitig  curved, 
a  line  is  drawn  from  its  tip  to  the  point  touched  by  the  finger. 
The  same  is  done  for  the  opposite  side  of  the  tumor. 

In  the  delivery  of  large  tumors  from  the  vagina,  after  their 


Medical  and  Surgical  Diseases  of  Women.  81 

expulsion  from  the  uterus,  he  recommends  the  following  pro 
cedures : 

1.  Seize  the  tumor  with  a  strong  forceps,  draw  it  down, 
sever  the  distended  perinseum  to  the  sphincter  ani,  partially  or 
completely  invert  the  uterus,  detach  the  tumor  by  means  of 
the  spoon-saw,  replace  the  uterus  at  once,  and  close  the  peri- 
nseum by  sutures. 

2.  Successive  sections  of  the  tumor  may  be  cut  away  by 
means  of  the  galvano-caustic  wire. 

3.  A  large  trocar  and  canula,  or  the  actual  cautery,  or  the 
trephine  obstetric  perforator,  may  be  used  to  channel  up  the 
middle  of  the  tumor,  and  then,  with  a  strong  pair  of  scissors, 
or  with  the  osteotome,  pieces  can  be  cut  out,  and  the  tumor  so 
diminished  in  size  that  it  is  susceptible  of  delivery. 

Dr.  Alfred  Post  finds  much  advantage  arising  from  passing 
a  strong  ligature  through  the  part  of  a  large  tumor  whieh 
projects  from  the  vagina.  This  is  a  more  powerful  means  of 
making  traction  than  by  the  use  of  the  Volsella  forceps  alone. 

In  the  removal  of  large  tumors  which  have  been  driven 
into  the  vagina,  Dr.  Thomas  Addis  Emmet  does  not  divide 
the  perinseum  or  enter  the  uterine  canal,  at  all.  He  believes 
that  the  fact  that  such  tumors  are  in  the  vagina,  shows  that 
the  uterus  is  strong  enough  to  drive  them  completely  out. 


ABORTION. 

Dr.  W.  T.  Lusk  thus  summarizes  his  views  on  this  sub- 
ject: 

1.  In  the  first  two  months,  an  abortion  needs  no  special 
treatment.     The  hemorrhages  of  early  date  are  amenable  to 
the  same  principles  of  treatment  as  those  from  the  non-preg- 
nant uterus. 

2.  In  the  third  month,  no  treatment  is  required,  when  the 
ovum  is  expelled  with  intact  membranes.     When  the  mem- 
branes rupture  previous  to  expulsion,  and  .hemorrhage  takes 


82  Notes  of  Hospital  Practice, 

place,  immediate  removal  should  be  attempted,  provided  that 
the  cervix  be  sufficiently  dilated  to  admit  the  index  finger. 
When  the  cervix  is  closed,  the  tampon  should  be  tried  for  24 
hours.  If  the  tampon  proves  ineffective,  the  cervix  should 
then  be  dilated  with  a  S{x>nge-tent,  and  the  ovum  removed 
with  the  finger.  The  finger  should  be  made  to  pass  up  along 
the  side  of  the  uterus,  across  the  fundus,  and  so  complete  the 
circuit  of  the  uterine  cavity. 

3.  In  cases  of  neglected  abortion,  retained  portions  should 
be  removed  by  the  finger  or  the  curette.     When  the  ovum  is 
decomposed,  no  dilation  of  the  os  is  usually  needed.     When 
the  ovum  is  fresh,  the  preliminary  use  of  sponge-tents  is  usu- 
ally demanded,  if  manual  delivery  is  resorted  to. 

4.  Fibrinous  polypi,  wlven  situated  near  the  os  internum, 
arrest  the  involution  of  the  lower  portion  of  the  uterus.    The 
os  is  therefore  open,  and  permits  the  passage  of  the  finger. 
When  the  polypus  is  attached  to  the  fundus,  the  cervix  is 
usually  closed.     Small,  smooth,  slippery  bodies,  like  fibriuous 
polypi,  are  rarely  to  be  detached,  unless  the  finger  operates 
from  above  so  that  the  choice  of  hands  depends  upon  the  side 
to  which  the  polypus  is  attached. 

5.  In  immature  deliveries,  hemorrhage  can  usually  be  con- 
trolled without  the  tampon,  by  compression  of  the  uterus,  and, 
in  cases  of  delay,  by  the  manual  extraction  of  the  placenta. 

Dr.  Fordyce  Barker  believes  that,  occasionally,  treatment 
is  required  in  abortion  occurring  in  the  first  two  months  of 
pregnancy.  In  these  early  abortions,  he  is  accustomed  to 
inject  into  the  vagina  a  very  large  quantity  of  very  hot  water, 
from  104°-110°  F.  He  is  sure  that  this  will  absolutely 
arrest  the  hemorrhage. 

In  cases  of  abortion  where  it  is  necsssary  to  tampon,  he 
docs  not  trust  to  any  kind  of  vaginal  tampon,  but  always 
plugs  up  the  cervix  uteri  with  a  compressed  sponge- tent,  and 
then  only  fills  up  the  vagina  sufficiently  to  keep  this  sponge 
in  place. 


Medical  and  Surgical  Diseases  of  Women.  83 

8OHE   NIPPLES. 

Dr.  F.  V.  White  is  in  the  habit  of  simply  protecting  the 
nipple  with  an  ordinary  nipple-glass,  secured  in  position  by 
means  of  a  bandage. 

Dr.  S.  S.  Purple  uses  the  following  : 

R     Taania  ..................................  ............  -------   3J. 

Syr.  acaeiie  ......  .......................  ...  ......  .....  ________  ..  f^ij. 

Aquae-...-  ................  —  .....  ....  ----------  ..  ......  .,„<.  f§  g.  M. 

This  is  applied  to  the  nipple  and  breast  with  the  finger, 
and  allowed  to  remain  exposed  to  the  air  .until  perfectly  dry. 
Dr.  Compton  uses  this  formula.: 

H     Tr.  benaoin.  co., 

»^^....»....»....^....»«.«.^*»»...^.».5a..  s.  M. 


OVASIOTOMY.. 

If  the  operation  «an  be  safely  delayed  for  a  week  or  more, 
after  coming  under  treatment,  Dr.  Nathan  Bozeman  prepares 
the  patient  by  administering  to  her  tonics  and  food  as  much 
as  she  can  bear.  Iron  he  considers  a  naest  valuable  agent  in 
the  preparatory  stage  of  ihe  treatraen  t.  The  an  tiseptie  method 
(Lister's)  l>e  invariably  uses  in  this,  as  in  all  major  operations. 
He  thinks  his  successes  are  greatly  due  te  the  means  thus 
adopted  of  preventing  peritonitis  and  septicaemia.  Whether 
long  or  short,  he  returns  the  pedicle  into  the  peritoneal  cavity, 
after  transfixing  and  tying  it,  right  and  left,  several  times 
with  waxed,  carbolized,  strong  silk  ligatures,  and  claims  that 
there  is  no  necessity  of  using  clamps  or  Koeberle's  serre-nseud. 
He  includes  the  peritoneum  in  his  sutures  when  closing  the 
abdominal  incision,  which  he  never  makes  larger  than  is  neces- 
sary in  the  median  line,  Oarbolized  silk  sutures  are  also  used 
for  closing  the  wound  as  for  tying  the  pedicle.  .Beef  tea,  milk 
and  eggs  constitute  the  food  given  as  soon  as  the  patient  has 
fully  recovered  from  the  anaesthetic,  (ether  being  used  for  this 


8  i  Notes  of  Hospital  Practice. 

puiyose.)  If  there  is  a  tendency  to  vomiting,  the  food  is  ad- 
ministered per  rectum.  Quinine  and  opium  the  doctor  con- 
siders of  the  highest  importance  in  the  after-treatment,  given 
in  full  doses,  as  being  antiperiodic,  and  a  preventive  of  peri- 
tonitis. Should  there  be  an  undue  elevation  of  temperature, 
not  controlled  by  the  medication  enumerated,  Kibbe's  cot 
comes  into  requisition.  The  first  incision  he  never  makes 
larger  than  is  necessary  for  the  introduction  into  the  peritoneal 
cavity  of  his  abdominal  spatula,  as  the  doctor  terms  it,  (a 
flexible,  metallic  rod,  10  to  12  inches  long,  well  rounded  off, 
with  a  triangular-shaped  termination  at  either  end,  like  Nott's 
vaginal  depressor,)  about  one  inch  long,  also  well  rounded 
off.  The  size  of  the  tumor,  its  adhesions,  if  there  be  any,  are 
thus  explored  with  the  aid  of  this  spatula.  The  incision  is 
then  enlarged  to  4-6",  for  the  purpose  of  introducing  the 
hand  and  separating  the  adhesions,  if  their  presence  has  been 
made  out,  in  the  mode  above  described.  The  next  step  con- 
feists  in  tapping  the  cyst  or  cysts  with  Spencer  Wells'  trocar. 
In  multilocular  cysts  he  taps  one  cyst  after  the  other,  through 
the  opening  made  in  the  first  cyst,  and  so  on,  the  patient 
being  turned  on  her  side.  The  cysts  are  thus  emptied  to  a 
size  sufficient  to  pass  his  right  hand  through  the  abdominal 
opening  into  the  peritoneal  cavity  while  drawing  out  the  cyst 
or  cysts  with  his  left.  This  simultaneous  use  of  both  hands 
Dr.  Bozeman  considers  of  the  utmost  importance  while  draw- 
ing out  the  cyst.  The  right .  hand  introduced  inside  the 
cavity  completes  the  separation  of  adhesions  that  may  have 
remained  after  the  use  of  his  spatula,  and  also  guards  against 
any  undue  stretching  or  possible  rupture  of  the  intestines, 
gall-bladder,  etc.,  with  which  there  may  be  adhesions.  The 
omission  of  this  precautionary  measure  doubtless  has  caused 
many  fatal  results  that  might  have  terminated  favorably  had 
this  precaution  been  practiced.  Six  to  8  grains  of  quiniae  sul- 
phate, and  25  drops  of  the  liquor  opii  comp.,  administered  per 
rectum,  are  the  doses  of  these  remedies  used  from  the  first  for 
the  purposes  mentioned.  The  use  of  hypoderniJc  injections  is 


Medical  and  Surgical  Diseases  of  Women.  85 

avoided  by  Dr.  Bozeman.  After  ovariotomy,  he  is  of  the 
opinion  that  on  account  of  the  pain  thereby  produced,  the 
patients  abhor  them,  and  thus  cause  undue  nervous  excite- 
ment. Dr.  Bozeman  never  uses  drainage  tubes  through 
Douglas'  cul-de-sac,  but  prefers  to  draw  off  effusions  by  means 
of  tubes  introduced  through  the  abdominal  opening,  reaching 
down  to  Douglas'  cul-de-sac. 

To  control  the  high  temperature  occurring  after  ovariotomy, 
Dr.  T.  G.  Thomas  recommends  the  use  of  "  Kibbe'-s  fever- 
cot."  This  cot  consists  of  a  strong,  elastic,  cotton  netting, 
manufactured  for  the  purpose,  tlirough  which  water  readily 
passes  to  the  rubber  cloth  below,  which  is  so  adjusted  as  to 
direct  the  stream  into  a  vessel  at  the  foot  of  the  bed.  His 
method  of  managing  his  patients  is  as  follows:  He  places 
upon  the  cot  a  blanket  or  sheet,  which  is  kept  constantly  wet 
by  pouring  cold  water  upon  it.  The  temperature  is  taken 
every  hour ;  bottles  of  warm  water  are  applied  to  the  feet  and 
hands;  the  patient  is  allowed  to  remain  upon  the  cot  as  long 
as  necessary,  constantly  enveloped  in  the  wet  sheet,  and  con- 
stantly exposed  to  the  influence  of  cold  water.  The  ur-ine  is 
drawn  with  a  catheter,  and  a  bed-pan  is  used.  His  aim  is  to 
keep  the  temperature  of  the  body  at  100°  F.,  or  a  little  less. 

PUERPERAL  CONVULSIONS. 

Dr.  S.  T.  Hubbard  lays  down  the  following  rules:  (1)  gen- 
eral blood-letting  is  called  for  when  headache  continues  after 
labor  is  completed,  and  is  attended  by  flushed  face,  restlessness 
and  convulsions  of  atonic  character.  Particularly  is  this  pro- 
cedure demanded  when  there  has  not  been  much  loss  of  blood 
at  the  birth  of  the  child ;  (2)  that  the  infusion  of  digitalis  is 
useful  to  steady  the  heart's  action,  to  allay  nervous  irritation, 
and  also  as  a  diuretic  when  aided  by  the  addition  of  the  bitar- 
trate  of  potassium  ;  (3)  that  chloroform  ought  to  be  used  spar- 
ingly;  (4)  that  the  continuous  action  of  chloral  hydrate  is 
greater  than  that  of  chloroform  and  that  k  is  less  likely  to 


86  Notes  of  Hospital  Practice. 

disturb  the  brain  ;  (5)  that  in  cases  in  which  there  has  been 
great  loss  of  blood,  or  great  prostration  attended  by  nervou* 
exhaustion,  dependence  may  be  placed  upon  hypodermic  injec 
tions  of  morphia  for  controlling  the  convulsions. 


AMENORRCEA   FROM   ANJEMIA. 

Dr.  A.  J.  C.  Skene  aims  first  at  restoring  the  normal  con- 
dition of  the  blood,  and  second,  at  re-establishing  menstrua- 
tion. Capricious  appetite,  coated  tongue,  and  constipation  he 
overcomes  by  giving  at  the  outset  a  cathartic  pill  composed  of 
pil.  hydrarg.  rubbed  up  with  glycerine,  syrup,  rhei  aromat 
and  carbonate  of  magnesia.  If  the  constipation  is  obstinate, 
the  following  prescription  is  used : 

fit     Quinise  sulph., 

Ferri  sulph aa  ^ij. 

Ex.  colocynth.  comp gr.  x. 

Ex.  belladon gr.  ijss.        M. 

Sio. — One  pill  before  each  meal. 

If  advisable,  aloes  is  substituted  in  place  of  the  colocynth. 

Among  ferruginous  tonics  Dr.  Skene  prefers  the  chlorate  of 
potassium  combined  with  the  tincture  of  the  chloride  of  iron. 
He  also  recommends  a  small  quantity  of  wine  or  alcohol  after 
meals. 

When  amenorrhoea  persists  after  the  anaemia  has  been  cured, 
he  gives  5-grain  doses  of  the  chloride  of  ammonium  every  3 
or  4  hours.  He  believes  that  this  drug  favors  the  rapid  ex- 
foliation of  the  epithelial  lining  of  the  endometrium.  Dr. 
Skene  is  opposed  to  the  employment  of  emmenogogues  in  this 
condition,  holding  that  they  almost  all  act  by  producing  irri- 
tation and  congestion  of  the  pelvic  organs. 


KETROFLEXION   OF  THE  UTERUS   WITH    HYPERJ3MIA. 

One  of  Dr.  Bozeman's  patients  had  been  subject  to  uterine 


Medical  and  Surgical  Diseases  of  Women.  87 

aemorrhage  more  or  less  severe  and  frequent,  and  the  fundus 
had  been  in  such  a  hyperaemic  condition,  that  the  slightest 
touch  of  the  probe  was  followed  by  quite  a  free  flow  of  blood. 
This  engorgement  was  treated  with  applications  of  a  solution 
of  carbolic  acid  in  glycerine,  of  the  strength  of  half  a  drachm 
to  the  ounce,  and  also  by  the  frequent  use  of  hot  vaginal 
douches.  Under  this  course  of  treatment,  decided  improve- 
ment had  taken  place,  notwithstanding  the  fact  that  it  was  as 
yet  impossible  to  restore  the  uterus  to  its  normal  position.  A 
little  later  it  was  proposed  to  accomplish  this  restoration  by 
gradual  pressure  upon  the  vagina  and  the  fundus  uteri  bj 
means  of  the  persistent  use,  for  a  sufficient  length  of  time,  of 
cotton  columns  applied  in  the  vagina,  in  accordance  with  the 
method  that  has  proved  so  successful  in  Dr.  Bozeman's  hands. 
The  plan  is  original  with  him,  and  is  somewhat  as  follows : 
The  patient  having  been  placed  in  the  knee-elbow  position, 
and  Bozeman's  speculum  introduced,  a  pledget  of  carbolized 
cotton  is  pushed  up  against  the  fundus  with  a  pair  of  dressing- 
forceps,  and  held  in  position  there  by  means  of  the  perineal 
elevator  ordinarily  employed  in  connection  with  this  speculum. 
A  second  and  third  pledget  is  then  applied  in  the  same  man- 
ner, the  perineal  elevator  being  drawn  a  little  further  out  as 
each  is  introduced ;  and  this  process  is  carried  on  until  a  firm 
column  of  cotton,  not  stuffing  up  the  whole  vagina,  but  of 
comparatively  narrow  diameter,  has  been  formed  that  reaches 
obliquely  from  the  fundus  of  the  uterus  to  the  symphysis 
pubis,  which  is  here  the  point  d'appui.  Such  a  column  may 
ordinarily  be  left  in  position  for  about  2  days,  but  is  not 
allowed  to  remain  for  longer  than  48  hours.  These  columns 
are  put  in  about  every  three  days,  the  patient  being  allowed 
to  rest  for  24  hours  after  the  removal  of  each  one,  and  vaginal 
douches  being  used  in  the  interval.  When  by  this  means  the 
uterus  has  been  restored  to  its  normal  position  and  the  vagina 
to  its  normal  condition,  any  appropriate  support  may  be  worn 
by  the  patient  as  long  as  is  necessary. 


88  Notes  of  Hospital  Practice. 

TREATMENT   OF   TYMPANITES. 

In  some  instances,  Dr.  T.  G.  Thomas  finds  systematic 
kneading  of  the  abdomen  to  be  of  service,  and  that  the  knee- 
chest  position  will  often  enable  the  patient  to  get  rid  of  a  con- 
siderable quantity  of  the  gas.  There  is  one  case  which  he 
mentions  particularly,  in  which  such  marked  tympanites  came 
on  after  ovariotomy  that  the  patient  nearly  died  in  consequence 
of  it.  When  this  method  was  resorted  to,  there  was  an  escape 
of  an  unlimited  amount  of  flatus  by  the  anus,  and  the  patient 
afterwards  made  a  good  recovery  from  the  operation. 

CHRONIC  OVARITIS. 

Dr.  T.  G.  Thomas  holds  that  the  patient  needs  feeding  up 
to  the  greatest  possible  extent,  in  addition  to  a  course  of  ap- 
propriate tonics.  One  of  the  best  of  these,  in  this  condition, 
is  the  syrup  of  the  hypophosphites,  which  is  now  so  frequently 
employed  in  the  incipient  stages  of  phthisis.  The  remedies 
employed  are  changed  from  time  to  time.  He  has  found  no 
other  treatment  for  chronic  ovaritis  nearly  so  good  as  change 
of  air  and  scene,  and  the  pleasurable  excitement  of  sight- 
seeing and  travel  in  cheerful  company,  although  he  does  not 
pretend  to  explain  exactly  in  what  manner  the  good  result  is 
brought  about. 

But  if  the  patient  is  not  able  to  travel  in  Europe,  she  is 
directed  to  make  use  of  very  copious  hot  water  vaginal  injec- 
tions at  least  twice  a  day,  and  three  times,  if  possible.  Then 
the  roof  of  the  pelvis  is  painted  once  a  week  with  compound 
tincture  of  iodine.  Iodine  is  also  applied  externally,  and  as 
often  as  two  or  three  times  a  week.  At  tiie  same  time,  elec- 
tricity is  faithfully  employed,  and  for  this  purpose,  Dr. 
Thomas  has  found  the  constant  current  the  only  one  that  is 
of  service,  the  faradic  current  being  rather  injurious  than 
beneficial.  The  best  way  to  apply  it,  he  thiuks,  is  for  the 
patient  to  lie  upon  one  electrode  while  the  other  is  carried  to 


Medical  and  Surgical  Diseases  of  Women.  89 

the  region  of  the  affected  ovary,  and  the  application  may  be 
made  once  or  twice  a  week.  For  at  least  a  week  preceding 
menstruation  absolute  rest  in  bed  is  insisted  upon,  (rest  being 
as  important  to  an  inflamed  ovary  as  to  an  inflamed  eye ;)  but 
she  is  permitted  to  get  up  as  soon  as  the  flow  makes  its  ap- 
pearance. 


KETROFLEXION    WITH    FISSURES   AND   STRICTURES    OF    THE 

RECTUM. 

The  proper  treatment  in  these  cases,  according  to  Dr.  M.  A. 
Fallen,  consists  in  keeping  the  bowels  well  open  by  enemata. 
In  addition  to  these,  the  woman  is  daily  put  in  the  geuu-pec- 
toral  position  and  her  uterus  thrown  well  forward  until  it  gets 
into  a  position  in  which  it  can  be  retained  by  a  pessary.  Such 
patients  as  these  are  naturally  and  habitually  constipated,  the 
toleration  of  the  rectum  being  really  wonderful. 

Dr.  Fallen  teaches  that  another  very  excellent  treatment  of 
these  cases  is  by  filling  the  rectum  with  very  large  quantities 
of  hot  water,  (as  the  bowel  can  be  educated  to  be  very  tolerant,) 
thereby  unfolding  the  rugae,  or  rather  expanding  them,  so  that 
the  very  bottom  of  the  rugous  fissures  can  be  washed  out,  and 
any  mucosities  or  pus  cleansed  therefrom.  After  the  gut  is 
thoroughly  washed  and  the  mucous  membrane  freed  from 
hyperseeretion,  he  considers  it  proper  to  touch  the  eroded  or 
ulcerated  spots  with  nitric  acid,  nitrate  of  silver,  or  even  the 
milder  non-caustic  astringents.  This  he  easily  accomplishes 
by  dilating  the  rectum  with  the  Sims  speculum.  But  all  treat- 
ment is  useless,  if  the  physician  fails  to  overcome  the  cause, 
i.  e.,  to  get  rid  of  retroflexion,  for  the  fundus  of  the  uterus 
jams  the  anterior  upon  the  posterior  wall  of  the  rectum,  as 
the  hyperfemia  produced  by  this,  as  well  as  the  accumulated 
faeces  above,  gives  rise  to  rectal  catarrh.  Dr.  Fallen  claims 
that  in  many  cases  of  this  character,  an  apparent  stricture 
ensues  which  is  in  reality  no  stricture  at  all,  but  is  a  symptom 


90  Notes  of  Hospital  Practice. 

of  obstruction,  giving  rise  to  the  very  distressing  conditions  of 
the  rectal  tenesmus  and  dysenteric  discharges. 


,    LEUCORRHOEA. 

Due  to  Fungoid  Growths  on  the  Endrometrium. — Dr.  T.  G. 
Thomas  treats  this  condition  by  passing  a  curette  np  to  the 
fundus,  either  after  or  before  dilatation  of  the  cervix,  and 
drawing  it  gently  over  both  walls  of  the  uterus.  After  this 
he  keeps  the  patient  quietly  in  bed  for  from  2  to  3  days, 
watching  for  the  occurrence  of  pain,  or  increase  of  tempera- 
ture. He  then  supports  the  womb  by  the  introduction  of  a 
pessary,  and  administers  either  viscum  album  in  the  form  of 
a  fluid  extract,  or  20-drop  doses  of  Squibb's  ergot  3  times  a 
day. 

Due  to  Insufficient  Diet  and  Consequent  Nervous  Depression. 
— Dr.  Thomas  insists  upon  it  that  such  patients  eat  fresh  meat 
3  times  a  day,  together  with  other  food,  and  that  they  take  a 
tumblerful  of  fresh  milk  between  meals.  At  the  same  time 
iron,  bitter  tonics,  and  beer  or  ale  are  ordered. 

Due  to  the  Presence  of  a  Cervical  Polypus. — The  leucorrhoea 
will  disappear  as  soon  as  the  polypus  is  snipped  off  with  the 
scissors.  Dr.  Thomas  lays  great  stress  upon  surgery  as  an 
element  of  gynaecology. 

Due  to  Ectropion  of  the  Lining  Membrane  of  the  Womb. — 
Dr.  Thomas  cures  these  cases  by  snipping  this  ectropion  on 
both  sides  and  turning  in  the  edges  of  the  mucous  membrane. 
He  keeps  the  vaginal  walls  contracted  by  the  use  of  astringent 
vaginal  injections. 

CHRONIC   UTERINE   CATARRH. 

The  first  thing  done  by  Dr.  Thomas  is  to  put  the  uterus  in 
its  proper  position  if  it  be  displaced.  It  is  then  kept  in  place 
by  means  of  an  anteversion  pessary,  and  vaginal  injections  ar<» 


Medical  and  Surgical  Diseases  of  Women.  91 

employed  constantly  to  keep  the  parts  free  from  irritation. 
After  the  next  succeeding  menstrual  period  the  endometrium 
is  carefully  and  thoroughly  scraped  with  the  curette  and  all 
the  fungoid  growths  removed. 


CARCINOMA   UTERI. 

Dr.  Thomas,  in  cases  which  are  destined  to  be  fatal,  aims 
(1)  at  controlling  the  hemorrhage,  (2)  at  relieving  the  pain, 
and  (3)  at  disinfecting  the  offensive  discharges.  The  plan 
which  he  pursues  is  as  follows :  first,  he  rapidly  cleanses  the 
vagina  aud  uterine  cavity  by  means  of  absorbent  cotton,  and 
then  applies  chemically-pure  nitric  acid  to  all  the  diseased 
surface.  This  generally  controls  the  hemorrhage  for  a  longer 
or  shorter  period. 

For  the  relief  of  pain  his  treatment  is  all  summed  up  in 
one  word,  and  that  is  opium.  If  it  does  not  suit  the  patient's 
stomach  it  is  given  by  the  rectum  or  hypodermically. 

He  overcomes  the  disagreeable  odor  of  the  discharges  by 
means  of  very  copious  vaginal  injections  given  3  times  a  day, 
and  consisting  of  water  containing  a  sufficient  amount  of 
thymol  or  carbolic  acid  to  act  as  a  disinfectant,  and  some  such 
simple  astringent  as  alum  or  sulphate  of  zinc. 

As  much  food  is  required  in  such  cases  as  can  possibly  be 
digested  by  the  patient.  Dr.  Thomas  considers  iron  and  the 
hypophosphites  as  utterly  useless.  He  regards  milk  as  the 
best  article  of  food,  6  ounces  being  given  at  first  every  3  hours 
and  afterwards  every  2  hours.  As  soon  as  practicable  a  large 
amount  of  cream  is  added,  so  that  the-  patient  may  take  2  ounces 
of  cream  to  every  4  ounces  of  milk.  In  this  way  he  has  been 
able  to  prolong  life  for  a  considerable  period  in  several  in- 
stances. 

PUERPERAL   PERITONITIS. 

The  opium  treatment  is  employed  by  Dr.  Clark  in  case? 


92  Notes  of  Hospital  Practice. 

where  peritonitis  is  the  most  prominent  element.  In  Bellevue 
Hospital  five  out  of  six  are  cured  by  this  treatment.  Besides 
the  opium,  his  patients  take  a  few  doses  of  veratrum  viride  to 
diminish  the  frequency  of  pulse.  He  gives  Norwood's  mix- 
ture of  veratrum  in  d6ses  of  gtt.  v,  when  the  opium  has  re- 
duced respiration  but  not  the  pulse.  It  sometimes  produces 
great  nausea,  attended  by  prostration  and  a  tendency  to  syncope. 
Alcoholics  are  used  when  such  effects  are  produced.  He  con- 
siders it  a  very  good  treatment  to  give  opium  and  veratrum 
viride  in  alternate  doses,  and  regards  this  as  all  that  is  neces- 
sary. In  metro-peritonitis  opium  does  not  serve  any  import- 
ant purpose,  and  he  thinks  it  useless  to  give  it,  except  to  soothe 
the  patient.  Leeches  to  the  vulva  or  perinseum  and  bleeding 
are  very  necessary.  He  very  often  employs  injections  of 
warm  and  tepid  water  into  vagina  and  uterus.  During  the 
period  of  purulent  infection,  he  prescribes  quinia  sulph.,  (gr. 
xv  per  day,)  combined  with  morph.  sulph.,  to  reduce  irrita- 
bility. If  there  is  a  tendency  to  the  formation  of  abscesses, 
food  and  stimulants  are,  of  course,  necessary. 


VESICO-UTERINE   FISTULA. 

Dr.  Bozeman's  operation  for  the  cure  of  this  condition,  con- 
sists in  the  complete  excision  of  the  anterior  lip  of  the  cervix 
uteri,  together  with  a  part  of  the  vesico- vaginal  septum,  thus 
converting  the  original  lesion  into  a  vesico-utero  vaginal 
fistula.  This  being  done,  the  posterior  lip  of  the  opening, 
which  was  the  stump  of  the  cervix  uteri,  is  next  pared  off,  as 
is  generally  done  in  fistulae  of  the  latter  class.  Four  silver- 
wire  sutures  are  needed,  which  are  introduced  by  a  straight 
needle  set  in  a  curved  needle- holder.  This  being  done,  the 
sutures  are  next  adjusted  in  the  usual  manner,  and  a  button 
or  plate  of  lead  of  suitable  form  and  size,  is  slid  down  upon 
them,  and  the  whole  then  secured  in  place  by  the  compression 
upon  each  wire  of  a  perforated  shot.  The  great  utility  claimed 
for  this  form  of  suture  in  the  operation  centres  in  the  leaden 


Medical  and  Surgical  Diseases  of  Women.  93 

plate,  which  stands  across  the  cervical  canal  and  prevents  its 
recontraction  and  the  consequent  puckering  of  the  line  of  co- 
aptated  edges,  until  union  takes  place.  After  washing  out 
the  bladder,  the  patient  is  placed  in  bed  and  quinise  sulph. 
gr.  x,  and  liq.  opii  cornp.  f  3  j.,  administered  per  rectum,  and 
followed  by  gr.  j  of  opium  by  the  mouth,  every  six  hours. 
Dr.  Bozeman  claims  great  advantage  in  the  operation  from 
the  use  of  the  self-sustaining  and  dilating  speculum.  By 
means  of  it  the  vagina  is  expanded  to  the  fullest  extent,  and 
the  greatest  facility  afforded  to  the  movements  of  instruments. 
The  advantages  of  the  knee-chest  position  are  also  fully  illus- 
trated. The  patient,  resting  upon  a  supporting  apparatus, 
takes  the  anaesthetic  with  the  greatest  comfort 


NERVOUS  DISEASES. 

SPEEMATOERHCEA. 

Constipation. — An  enema  of  cold  water  is  ordered  every 
morning.  This  not  only  produces  a  normal  evacuation,  but 
also  stimulates  the  blood-vessels  and  the  surrounding  parts  to 
a  more  vigorous  contraction  and  accelerates  their  return  to  a 
normal  condition. 

Derangement  of  Digestion. — A  diet  is  recommended  by  Dr. 
Joseph  W.  Howe  calculated  to  increase  the  patient's  vitality, 
and  consisting  of  oysters,  eggs,  milk,  beef,  mutton,  etc. 

Stimulants. — Some  mild  wine,  such  as  claret,  is  prescribed, 
which  will  promote  good  digestion  without  exciting  inordinate 
desires. 

Bathing. — The  patient  is  directed  to  take  a  cold  sponge- 
bath  every  morning.  Cold  water  is,  at  the  same  time,  ordered 
to  be  thrown  into  the  rectum. 

Exercise  of  all  kinds  is  advised,  with  the  exception  of  horse- 
back riding. 

Local  Treatment. — Dr.  Howe  does  not  recommend  caustics 
or  the  passage  of  the  sound,  but  thinks  very  highly  of  elec- 
tricity. One  electrode  is  insulated  to  nearly  its  entire  extent, 
except  that  part  which  rests  against  the  prostatic  urethra. 
The  other  electrode  is  applied  over  the  fourth  lumbar  verte- 
bra. Only  a  very  feeble  current  is  allowed  to  pass  through 
at  first,  and  the  first  sitting  only  lasts  five  minutes.  The 
second  day,  the  wire-brush  is  used,  passing  it  over  the  inside 
of  the  thighs,  about  the  perinseum.  On  the  third  day,  the 
urethral  electrode  is  again  employed.  The  strength  of  the 
current  is  gradually  increased  with  each  sitting. 

Medical  Treatment. — One  of  the  best  tonics,  in  Dr.  Howe's 
opinion,  is  this : 

(94) 


Nervous  Diseases.  95 

R     Strych.  sulph gr.  j. 

Quin.  sulph gss. 

Tc.  ferri  mur f£  ss. 

Glycerines f  J  iv.  M. 

SIG. — One-half  teaspoonful  in  a  wineglass  of  water,  four  times  a  day, 

half  an  hour  before  meals,  and  at  bedtime. 

This  is  another  favorite  prescription  : 

R     Ferri  arsen., 

Ex.  nuc.  vom aa  gr.  v 

Ergot., 

Quin.  sulph aa  £88.  M. 

Et  in  pil.  No.  xxx  div. 
SiG. — One  pill  four  times  a  day. 

Where  constipation  is  a  prominent  symptom,  gr.  x  of  aloes 
are  substituted  for  ergot,  in  the  above. 
Impotence : 

R     Ex  nuc.  vom. gr.  I. 

Phosphor gr.  ^fa.        M. 

SIG. — To  be  taken  after  meals. 

In  some  cases,  f  3  ss  doses  of  the  fluid  extract  of  damiana 
are  substituted  for  the  phosphorus,  with  advantage,  or,  another 
excellent  remedy,  f3ss-j  of  the  tincture  of  water  pepper. 
Here  are  three  prescriptions  which  he  frequently  uses : 

1.  R     Tc.  canthar., 

Tc.  nuc.  vom., 

Tr.  ergot aa  f^j.  If. 

SIG. — Ten  to  twenty  drops,  four  times  daily. 

2.  R     Tr.  sanguinarise :..  f^ss. 

Fl.  ex.  stillingise f^ij.  M. 

SIG. — Twenty  to  thirty  drops,  four  times  a  day. 

3.  R     Capsici gr.  x. 

Quin.  sulph gr.  r. 

Vini  xerici f£  jsi.  M. 

SIG. — To  be  taken  at  bedtime. 


96  Notes  of  Hospital  Practice. 

Over-Excitement  of  the  Genital  Organs. — This  is  controlled 
by  gr.  xx  of  bromide  of  potassium  at  night,  and  four  times 
a  week.  During  the  second  week,  the  dose  is  increased  to 
gr.  xxx.  The  use  of  the  bromide  is  always  preceded  by  a 
brisk  cathartic.  According  to  Dr.  Howe,  the  radical  cure  of 
this  class  of  cases  consists  in  the  patient's  getting  married. 


TUBERCULAR   MENINGITIS   IN   CHILDREN. 

Dr.  Delafield  does  not  care  to  disturb  the  child  by  applying 
blisters  to  the  nape  of  the  neck,  etc.  He  quiets  the  vomiting 
and  increases  the  amount  of  urine  secreted  by  the  kidneys  by 
administering  the  bicarbonate  of  potassium  and  lemon  juice. 
In  order  to  still  further  increase  the  secretion  of  urine,  the 
child  is  placed  in  a  tub  of  warm  water  for  about  five  minutes, 
then  removed,  and,  without  drying  the  skin,  wrapped  in  warm 
blankets  and  allowed  to  sweat  for  two  or  three  hours.  When 
something  is  required  to  keep  the  patient  quiet,  a  mixture  of 
chloral  hydrate  and  bromide  of  potassium  is  given. 

MIGRAINE. 

Dr.  Eugene  Depuy  has  obtained  good  results  in  some  cases 
by  introducing  brandy  or  strong  snuff  into  the  nostril  upon 
the  side  corresponding  to  that  upon  which  the  pain  is  felt. 
Another  excellent  method  of  treatment  is  by  throwing  car- 
bonic acid  gas  against  the  nasal  mucous  membrane  in  a  suffi- 
ciently strong  jet  to  produce  a  marked  impression.  In  still 
other  cases,  Dr.  Depuy  has  administered  the  so-called  "  potion 
of  Riverius,"  which  consists  of  citric  acid  and  simple  syrup, 
and  bicarbonate  of  potassium  and  water,  adding  to  it  bromide 
of  potassium.  This  is  an  effervescing  mixture,  and  is  admin- 
istered in  alternate  tablespoonfuls,  allowing  effervescence  to 
take  place  in  the  stomach.  He  recommends  also  occasional 
mustard  plasters  to  the  nape  of  the  neck,  and  the  use  of  mild 
aloetic  aperients. 


Nervous  Diseases.  97 

Dr.  E.  C.  Seguin  recommends  that  when  a  patient  wakes 
in  the  morning  with  a  feeling  as  if  a  headache  were  imminent, 
a  drachm  of  paullinia  powder,  or  the  same  quantity  of  its 
equivalent,  the  elixir  or  fluid  extract  of  guarana,  be  taken, 
the  dose  to  be  repeated  in  the  course  of  an  hour,  unless  re- 
lieved. When  the  pain  is  severe,  he  does  not  hesitate  to  use 
a  hypodermic  of  ^JIQQ  of  a  grain  of  atropia,  combined  with 
from  5  to  15  minims  of  Magendie's  solution. 

In  the  intervals  between  the  attacks  he  administers  £  a 
grain  of  the  solid  extract  of  cannabis  iudica,  daily — this  dose 
being  kept  up  for  a  long  time  continuously. 

Dr.  G.  M.  Beard  has  had  very  good  results  from  the  ad- 
ministration of  caffeine,  just  before  the  attack,  and  of  from  15 
to  20  grains  of  the  muriate  of  ammonia. 


TEIGEMINAL   NEURALGIAS. 

Dr.  E.  C.  Seguin  has  obtained  invariably  good  results  from 
the  use  of  Duquesnel's  aconitia.  His  average  dose  is  1/100  of  a 
grain  every  four  hours.  He  has  found  that  the  susceptibility 
of  individuals  to  this  preparation  varies  exceedingly.  Some 
are  over-affected  by  the  i/200  of  a  grain,  while  others  take  the 
*/84  w^h  impunity.  He  concludes  that  Duquesnel's  aconitia 
is  the  most  powerful  and  the  best  remedy  for  the  relief  and 
cure  of  trigeminal  neuralgia. 


CEREBRO-SPINAL  MENINGITIS. 

Dr.  Thomson  administers  teaspoonful  doses  of  the  fluid  ex- 
tract of  ergot  and  gr.  v  of  quinia  every  three  hours.  One- 
twentieth  of  a  grain  of  calomel  is  given  every  half-hour. 
Leeches  are  applied  to  the  spine,  and  ice  to  the  head  and 
back.  If  the  pulse  is  feeble,  f  3  iv  of  whiskey  are  given  every 
half  hour. 

The  following  is  sometimes  useful  : 


98  Notes  of  Hospital  Practice. 

A     Potaaii  iod gr.  xl. 

Ex.  conii  fl gtt.  xl. 

Aquae q.  s.  ad  f|  ij.  M. 

SIG. — Two  fluid  drachms  thrice  daily. 


HEMIPLEQIA. 

If  of  syphilitic  origin  Dr.  Thomson  gives  the  iodide  of  po- 
tassium in  doses  of  a  drachm  and  upwards.  He  also  recom- 
mends : 


R     Acid.  phos.  dil 

Syrup.  hypophos_  ............................  q.  s.  ad  f^  iv.  M. 

SIG.  —  Two  teaspoonfuls  in  water  thrice  daily. 

The  patient  is  placed  as  much  as  possible  upon  a  vegetable 
and  fruit  diet.  Meat  is  forbidden,  and  milk,  eggs  and  fish 
allowed  only  in  small  quantities.  Tea  and  coffee  are  taken 
but  once  a  day  ;  all  alcoholics,  especially  malt  liquors,  are  for- 
bidden. Moderate  exercise  in  the  fresh  air  is  advised,  but 
fatigue  is  always  to  be  avoided.  Iron  is  given  when  muscular 
degeneration  is  feared,  and  corrosive  sublimate  prescribed  in 
doses  of  1/30  granl>  thrice  daily  for  a  long  period  of  time. 


CEREBRAL   HEMORRHAGE. 

Dr.  Hamilton  meets  increase  in  the  frequency  of  the  pulse 
and  elevation  in  temperature,  by  local  derivatives  and  cardiac 
sedatives.  He  thinks  it  unwise  to  use  electricity  in  any  form, 
if  degeneration  lias  begun.  If  there  is  pain,  the  actual  cau- 
tery is  applied  over  the  nerve  trunks.  He  has  derived  the 
greatest  benefit  from  wrapping  the  limbs  carefully  with  cotton 
batting,  and  covering  it  with  oil  silk.  Tremor  is  controlled 
by  conium  and  the  avoidance  of  general  excitement.  Hot 
baths  and  soaking  the  limbs  for  10  or  15  minutes,  daily,  in 
water  as  warm  as  the  patient  can  bear  it,  are  useful. 


Nervous  Diseases.  99 

PROGRESSIVE   MUSCULAR   ATROPHY. 

Dr.  Hamilton  employs  electricity,  and,  if  the  extensors  are 
atrophied,  gives  support  to  the  hand  by  means  of  the  rubber 
muscle. 

POLIO-MYELITIS 

S 

Is  treated  by  electricity,  with  a  minimum  galvanic  current, 
and  gradually  increasing  its  strength,  allowing  the  muscles  to 
rest  for  a  day  or  so  between  each  seance.  In  addition  to  elec- 
tricity, Dr.  Hamilton  has  employed  cod-liver  oil,  the  syrup 
of  the  iodide  of  iron,  and  strychnia,  with  advantage. 

SCLEROSIS   OP  THE  SPINAL   CORD. 

In  the  early  stages,  Dr.  A.  McLane  Hamilton  uses  ergot 
with  good  results.  Later,  he  relies  mainly  upon  phosphorus 
and  cod-liver  oil,  joined  with  galvanization  and  cauterization 
of  the  cord.  For  the  relief  of  the  pains,  he  finds  that  hypo- 
dermic injections  of  atrophia,  morphia,  or  muscarine,  act  most 
favorably.  For  the  same  purpose  he  employs  the  galvanic 
current,  placing  the  positive  pole  over  the  painful  point  in 
the  back.  Warm  sulphur  baths,  made  by  simply  dissolving 
an  ounce  or  so  of  the  sulphuret  of  potassium  in  water,  of  a 
temperature  not  exceeding  90°  F.,  are  useful  adjuvants. 

EPILEPSY. 

• 

Dr.  A.  McL.  Hamilton  insists  upon  a  careful  observance 
of  hygienic  rules.  As  regards  medicine,  he  is  in  the  habit  of 
combining  the  bromide  of  sodium  with  equal  parts  of  the 
bromide  of  ammonium,  and  of  administering  1  j  of  the  com- 
bined salts,  daily,  together  with  gr.  xxx  of  the  hydrate  of 
chloral.  The  doses  are  divided  so  that  the  largest  is  given 
just  before  the  fit  is  expected.  In  other  cases,  Brown- 


100  Notes  of  Hospital  Practice. 

Sequard's  mixture  of  the  bromides  with  bicarbonate  of  potas- 
sium and  a  bitter  tonic,  acts  admirably. 

Dr.  Hamilton  regards  it  as  of  the  utmost  importance  to 
combine  cod-liver  oij,  cream,  extract  of  malt,  or  linseed  oil, 
with  the  bromide,*  in  the  treatment. 

Where  the  disease  has  no  specific  cause,  he  resorts  to  the 
use  of  the  actual  cautery,  or  applies  repeated  blisters  to  the 
back  of  the  neck.  He  believes  curare  to  be  indicated  in 
obstinate  cases,  and  injects  a  standard  solution  of  this  drug, 
acidulated  with  diluted  hydrochloric  acid,  hypodermically, 
every  fifth  day,  in  doses  of  £  of  a  grain,  until  five  or  six 
doses  are  given.  In  the  lighter  forms  of  the  disease,  he 
employs  f3 j  doses  of  the  fluid  extract  of  ergot,  thrice  daily, 
alternated  with  gtt.  v  doses  of  tincture  of  belladonna,  the 
quantity  being  gradually  increased. 

When  the  case  gives  a  specific  history,  he  combines  the 
iodide  of  potassium,  or  better  still,  the  bichloride  of  mercury, 
with  the  bromides,  pushing  the  administration  of  the  former 
drugs  as  far  as  he  can  with  safety. 

Dr.  E.  C.  Seguin  treats  idiopathic  epilepsy  with  the  follow- 
ing formulae: 

R     Potassii  brom J  j. 

Ammon.  brom %  ss. 

Aquae  font f^  vij.  M. 

SlG. — To  be  given  by  the  teaspoonful. 

R     Sodii  brom ^j. 

Ammon.  brom %  88. 

Aquae  font f£  vij. 

SlG. — To  be  given  b£  the  teaspoonful. 

The  quantity  administered  is  so  divided  as  to  give  the  larg- 
est dose  in  the  evening.  The  dose  is  gradually  increased  to 
the  production  of  bromism.  The  dose  is  administered  in  a 
tumblerful  of  water.  The  bromides  are  continued  for  at  least 
three  years  after  the  last  attack.  The  acne  consequent  upon 
the  long-continued  use  of  the  bromides,  is  combated  with 


Nervous  Diseases.  101 

arsenic,  sulphur  ointments,  mercurial  plaster,  and  alkaline 
lotions.  To  correct  the  debility  and  paresis,  strychnia,  mix 
vomica,  the  oxide  of  zinc,  and  quinia,  are  given.  Nitrate  of 
amyl  and  stimulants  relieve  the  dizziness.  The  patient's  diet 
is  regulated.  Cream,  cod-liver  oil,  iron,  quinia,  phosphorus, 
strychnia  with  nitro-muriatic  acid,  wine,  beer,  and  whiskey, 
are  taken  steadily,  as  tonics  and  nutrients. 


INSANITY. 

The  bromides  are  employed  by  Dr.  Segtrin  to  meet  such 
indications  as  epileptiform  attacks,  or  abnormal  sexual  excite-" 
ment,  or  great  nervousness  not  caused  by  delusions. 


FACIAL   NEURALGIA 

Is  treated  at  the  Presbyterian  Hospital  by  croton  chloral 
given  in  solution  with  elixir  calisaya;  5  grains  3  times  a  day 
for  a  week. 

INSOMNIA. 

Dr.  E.  C.  Seguin  prescribes  chloral  in  some  cases,  and  in 
others  some  stimulant,  such  as  beer.  He  does  not  place  much 
confidence  upon  the  use  of  the  bromides  here 

HAY-ASTHMA. 

Dr.  Seguin'uses  this  gargle : 

R     Ammon.  brom.,  (3J  to  ^ij-fjj) fj  vj.  M. 

SIG. — To  be  used  as  a  gargle. 

The  nasal  passages  are  washed  out  sev«ral  times  a  week 
with  a  weak  solution  of  the  same  salt,  (gr.  x-xxx  to  f  3  j.) 


102  Notes  of  Hospital  Practice. 

CHOREA. 

If  the  child  is  run  down,  Dr.  Hamilton  administers  iron 
and  cod-liver  oil.  Strychnia  is  given  up  to  the  point  of  pro- 
ducing stiffness  of  the  sural  muscles.  He  thinks  that  the 
application  of  cold  to  the  spine  cannot  be  over-estimated  as  a 
plan  of  treatment.  He  either  employs  the  ether  spray,  or 
applies  ice-bags,  allowing  them  to  stay  on  about  ten  minutes. 

The  spray  is  directed  to  the  upper  part  of  the  cord,  over  the 
upper  cervical  vertebrae.  Eserine  he  regards  as  a  dangerous 
remedy  and  one  likely  to  produce  severe  gastric  symptoms. 
Where  nothing  else  does  good,  Dr.  Hamilton  is  accustomed  to 
'put  his  patients  in  a  dark  room  and  keep  them  quiet.  The 
diet  is  carefully  regulated.  Among  useful  hygienic  measures 
are  the  salt  bath  and  the  energetic  use  of  the  rough  towel. 

SPINAL   ANAEMIA. 

Dr.  Hammond  prescribes  gr.  I/^Q  of  the  phosphide  of  zinc 
with  gr.  |  of  the  extract  of  nux  vomica,  in  pill  form,  to  be 
taken  three  times  a  day.  Lately  he  has  pursued  the  practice 
of  giving  strychnia  in  gradually  increasing  doses,  until  there 
is  some  evidence  of  the  production  of  its  characteristic  physi- 
cal effects.  He  dissolves  gr.  ij  of  the  sulphate  of  strychnia  in 
f  §j  of  water,  and  gives  Ifl  x  (containing  gr.  l/24  of  strychnia) 
three  times  during  the  day.  On  the  next  day,  TT^xj  are  given 
at  each  dose,  and  on  the  third  day  Tl^xij,  and  so  on  until  the 
paralysis  yields,  or  the  muscles  of  the  legs  become  stiff.  In 
this  latter  case,  the  use  of  the  drug  is  stopped  for  a  day,  and 
on  the  next  day  he  begins  again  with  the  original  dose. 

ACUTE   CEREBRAL   MENINGITIS. 

If  the  cephalalgia  is  intense,  Dr.  Hammond  takes  as  much 
as  12  or  16  ounces  of  blood  from  the  arm.  Leeches  are  ap- 
plied behind  the  ears.  The  hair  is  cut  off  short,  and  ice  kept 


Nervous  Diseases.  103 

constantly  applied  to  the  scalp.  As  a  purgative,  gr.  x  of 
calomel,  and  gr.  ij  of  podophyllin,  are  administered.  He  haa 
derived  the  greatast  benefit  from  the  bromide  of  potassium,  in 
30-gr.  doses  three  or  four  times  a  day.  The  head  is  kept 
well  elevated  and  care  is  taken  to  keep  the  room  in  which  the 
patient  lies,  cool  and  well  ventilated,  and  to  exclude  the  light 
as  much  as  possible.  As  food,  the  chief  reliance  is  placed 
upon  strong  beef  tea.  "When  the  strength  flags  in  the  later 
stages  of  the  disease,  alcohol  is  administered  in  appropriate, 
doses. 


HYOSCYAMIA   AS  AN  HYPNOTIC  AND   ANTISPASMODIC. 

Dr.  E.  C.  Seguin  reaches  the  following  provisional  conclu- 
sions with  regard  to  the  modes  of  action  of  this  drug  : 

1.  It  acts  upon  the  pupil  as  a  mydriatic. 

2.  It  reduces  the   pulse  gradually  and   increases  arterial 
tension. 

3.  It  checks  bodily  heat. 

4.  It  produces  hallucinations  and  delirium. 

5.  Its  use  is  occasionally  attended  by  a  rash. 

6.  In   large  doses,  it  produces  sleep,  and  something  like 
paralysis  or  paresis,  and  may  induce  retention  and  dysuria. 

7.  Theoretically,  it  is  indicated  in  mania  attended  by  rest- 
lessness, delusions  and  suspicions,  and  in  insomnia  and  convul- 
sive affections. 

8.  It  has  been  of  especial  service  in  acute  or  subacute  mania, 
insomnia,  and  those  cases  characterized  by  mischievous  delirium. 

9.  It  induces  sleep  more  certainly  than  chloral,  and  without 
being  followed  by  bad  effects. 

10.  In  paralysis  agitans  it  can  do  what  no  other  remedy 
can  do. 

11.  It  is  a  diuretic  of  no  mean  power. 

12.  Its  curative  power  does  not  seem,  to  be  great. 

13.  In  acute  chorea  its  use  may  play  an  important  part. 
Mode  of  Administration  and  Proper  Dose. — It  can  be  given 


104  Notes  of  Hospital  Practice. 

in  small  doses,  hypodernaically,  with  ease.  The  doses  aw 
from  1/20  to  1  grain  of  the  amorphous,  and  from  l/10o  to  1/25 
of  a  grain  for  hypodermic  use.  Distinct  effects  may  be  ob- 
tained from  the  ^/joo  ®f  a  grain. 

The  following  formula  is  given  for  hypodermic  use: 

R     Hyoscyamiae  (Merck's  eryst.)  .......  ..  ...............  gr.  j. 

Glycerinae, 

Aquae  .......  ^...  ...-„..»  ...............................  aa  TT^  100. 

Acid.  carb.  purse  .........................................  gtt.  j.  M. 


Each  minim  contains  1/200  °f  a  gra'n« 
Tablets  containing  1/50  of  a  grain  are  convenient  for  use  by 
the  mouth, 


Dr.  Hammond  regards  the  alcoholics  as  the  indications  par 
excellence.  The  quantity  employed  is  small  at  first  and  is 
administered  frequently  and  in  a  highly  diluted  form.  When 
alcohol  cannot  be  employed,  the  carbonate  or  aromatic  spirits 
of  ammonia  are  given. 

As  a  tonic  he  regards  tins  mixture  as  of  great  value : 

R     Strychnise  sulph ^ ~.  gr.  j. 

Ferri  pyrophos., 

Quinise  sulph „ .. aa  3J. 

Acid.  phos.  dil., 

Syr.  zingiber .... ~ aa  f^  ij.  M. 

Ft.  mist. 
SiG. — A  teaspoonful  three  times  a  day  in  a  little  water. 

The  diet  used  must  be  of  good  quality,  consisting  chiefly  of 
milk,  eggs,  and  meat  of  various  kinds. 

The  patient  is  encouraged  to  pass  a  good  portion  of  each 
day  in  a  recumbent  position.  Emotional  disturbance  and 
anything  above  moderate  mental  exercise  is  to  be  sedulously 
avoided. 

Bromide  of  potassium  is  strongly  counter-indicated. 


Nervous  Diseases.  10-3 

SPINAL  CONGESTION. 

T:i  cases  which  come  on  suddenly,  Dr.  Hammond  draws 
blood  from  the  spine  by  cups  or  leeches.  He  thinks  the  verge 
of  the  anus  the  best  place  for  the  application  of  the  latter.  As 
a  purgative  he  administers  3  j  doses  of  the  sulphate  of  mag- 
nesia 2  or  3  times  a  day.  He  regards  the  ergot  of  rye  as  of 
great  value  in  this  disorder,  and  gives  it  in  f  3j  doses  of  the 
fluid  extract  3  times  a  day.  When  there  is  paralysis  of  the 
sphincter  of  the  bladder,  or  when  the  pain  in  the  back  is 
severe,  gtt.  xv  doses  of  the  tincture  of  belladonna  3  times  a 
day,  and  a  belladonna  plaster  is  applied  to  the  painful  region 
of  the  spine.  He  has  found  the  hot  douche  to  be  an  excellent 
means  of  drawing  the  blood  from  the  deep  to  the  superficial' 
vessels  of  the  spine.  The  water  is  allowed  to  fall  upon  the 
naked  back  over  the  diseased  part  of  the  cord  every  day  for 
al>out  5  minutes.  Dry  cups  have  also  been  found  to  be  valu- 
able adjuncts.  The  constant  current  is  applied  to  the  spine 
over  the  affected  part  of  the  cord,  the  positive  pole  being  held 
at  the  upper  limit  of  the  lesion  and  the  negative  pole  rubbed 
up  and  down,  over  all  the  parts  below.  T^ie  seances  should 
not  exceed  10  minutes  in  length.  ^  s  an  application  to  the 
paralyzed  muscles  the  induced  current  is  employed,  being  used 
every  day  for  half  an  hour  or  so  at  a  time. 

Dr.  Hammond  considers  that  phosphorus  and  strychnia 
should  never  be  given  in  cases  of  spinal  congestion. 


INDEX. 


Abortion .81-82 

Abscess ~.~. 64 

Acne  Rosacea. ».21-22 

Alimentation,  Rectal «....     18 

Amenorrhcea  from  Anaemia 86 

Ammonia,  Intravenous  Injection 

of 17 

Anaemia,  Amenorrhoea  from. 86 

"      ,  Cerebral 104 

"       ,  Spinal  _ 102 

Anchylosis,  Fibrous... 59-60 

Angina  Pectoris..- ,.-.....~.....     51 

Ano,  Fistula  in ~~     62 

Anthrax 64 

Aortic  Lesions .....~     51 

Asthma 6 

"      ,  Hay Ml 


Boracic  Acid  as  an  Anodyne-...    63 
Bright's  Disease,  Chronic 

31-32  and  47 
Burns 44 

0. 

Cancer  of  Tongue,  Ligation  of 
Sublingual  Artery  for  Remov- 
al of. i 58-59 

Catarrh,  Chronic  Uterine ..90-91 

"      ,  Naso-Pharyngeal 29-31 

Cervix  Uteri,  Laceration  of. 79 

Chancre 68-70 

Cholera  Infantum 39-40 

Chorea 102 

Colles' Fracture....  ....66-67 


Oough  Mixture,  A  Disinfectant 

and  Antiseptic 53 

Congestion,  Spinal 105 

Constipation    associated     with 

Chlorosis 49-50 

Constipation  dependent  upon  de- 
ficient Secretion 48 

Constipation  due  to  Chronic  In- 
flammation of  the  Rectum 49 

Constipation  due  to  want  of  Per- 
istaltic Action 49 

Constipation   following  Febrile 

Diseases 49 

Contusions 51 

Convulsions,  Puerperal 85-86 

Cystitis  following  Gonorrhcea...73-74 
Cystorrhagia 74-75 

D. 

Diabetes  Ineipidus  in  Children...    53 

Diarrhoea,  Beef  Tea  in 32 

"       ,  Chronic,  in  Adults...l5-17 
•"         due  to  Errors  in  Diet, 

36-37 
"         due  to  Inflammatory 

Disorders 35 

Diarrhoea  due  to  Preternatural 

Acidity 37 

Diarrhoea,  Dysenteric 33-34 

"       .Flatulent 34 

"       ,  General  Hints  in.. ..38-39 

•"       ,  Koumyss  in 34-35 

"       ,  The,  of  Dentition... 37-38 
u       ,The     Reduction     of 

Temperature  in 32-33 

Diphtheria 5-6 

Dysentery,  Acute 14-15 


V07 


108 


INDEX. 


Dysentery,  Chronic 15 

"        ,  Epidemic 15 

E. 

Ear,  Accumulations  in  the 19 

"  ,  Catarrhal  Inflammation  of 

Middle 46-47 

Ear,   Chronic   Suppurative   In- 
flammation of  Middle 7-9 

Eczema  Rubra 66 

Emesis 19 

Emphysema 52-53 

Empyema 3-4  and  62-63 

Enteritis,  Subacute 15 

EpididymitiB 67-68 

Epilepsy 99-101 

Epistaxis 53 

P. 

Favus 50 

Femur,  Fractures  of. 67 

Fever,  Scarlet ...51-52 

"    ,  Typhoid -. 22-28 

"    ,         "       in  Children....40-42 

Fibula,  Fracture  of. 67 

Fistula,  Perineal 68 

"     ,  Vesico-Uterine 92-93 

G. 

Gonorrhoea,  Cystitis  following..73-74 

H. 

Haemoptysis 14 

Haemorrhoids,  Internal 64-66 

"  ,  Treatment  of.... 7 1-72 

Headache  dependent  on  Gout...    43 

"        ,  Dyspeptic 44-45 

"         of  Acute  Alcoholism      44 
"         "       "     Cerebral 

Congestion 45-46 

Headache   of  Passive  Cerebral 

Congestion 46 

Headache  of  Cerebral  Anaemia...    46 


Headache  of  Cerebral  Effusion...     44 

"         "        "        Softening,    4(J 

Tumors...     46 

"          "Rheumatism 43 

u         "Syphilis 43 

"       ,  Malarial 43 

"       ,  Nervous 42 

"       ,Sick 42-43 

"       ,Ursemic 43-44 

Heart,  Disease  of  the 50-51 

Hemiplegia 98 

Hemorrhage,  Cerebral 98 

"          ,  Post-Partnm 78 

Hernia,  Stangulated  and  Incar- 
cerated  .'..57-58 

Hip-joint,  Luxation  at  the 54-55 

Hyoscyamia  as  an  Hypnotic  and 
Antispasmodic 103-101 

I. 

Insanity 101 

Insomnia 101 

J. 
Jaundice 11 

L. 

Laryngitis,  Catarrhal 48 

Leprosy,  The  Larynx  of. 31 

Leucorrhcea  due  to  Ectropion  of 
the  Lining  Membrane  of  the 
Womb 90 

Leucorrhcea  due  to  Fungoid 
Growths  on  the  Endome- 
triura 90 

Leucorrhoea  due  to  Insufficient 
Diet  and  Consequent  Nervous 
Depression 90 

Leucorrhoea  due  to  the  Pressure 
of  a  Cervical  Polypus 90 

Lingual  Artery,  Ligation  of,  in 
Removal  of  Cancer  of  the 
Tongue 58-59 

Lip,  Cancer  of  the  Lower 60-61 


INDEX. 


109 


Liver,  Cirrhosis  of  lite _..~  20 

Locomotor  Ataxia,  Treatment 

of  the  Paius  of. 12-13 

Lungs,  Gangrene  of. 13 

"     ,  Multiple  Abscess  of. 13 

M. 

Mamma,  Scirrhus  of  the 59 

Meningitis,  Acute  Cerebral...l02-103 

"        ,  Cerebro-Spinal 97-98 

"        ,  Tubercular,  in  Chil- 
dren  9€ 

Menorrhagia 77-78 

Migraine  -96-97 

Morphia  Vomiting. „.—....     19 

Muscular  Atrophy,  Progressive,     99 

N. 

Nsevus . 55 

Nephritis,  Chronic. 20 

Neuralgia,  Facial 101 

"        ,  Trigeminal 97 

Nipples,  Sore 83 

O. 

Opium  Poisoning 19 

Ophthalmia  Neonatorum 17 

Otorrhoea,  Acute  Primary 17-18 

Ovariotomy 83-85 

Ovaritis,  Chronic 88-89 

P. 

Patella,  Fractured 67 

Pelves,  Labor  in  Kyphotic 77 

Perineum,  Laceration  of  the 77 

Peritonitis,  Puerperal 91-92 

"        .Sporadic 11-12 

Pleurisy,  Acute 9 

"      ,  Subacute „ 6-7 

Pharyngitis,  Croupous 22 

Phthisis,  Aphthae  of. 10 

"      ,  Diarrhoea  of. -     10 

"      ,  Laryngeal 28-29 

"      ,  Sore  Throat  of 10-11 


Phtliisis,  The  Eheumatism  of....     14 

"      ,  Vomiting  in 10 

Pneumonia,  Acute 1-3 

"        .,  Broncho- 20-21 

,  Chronic 13-14 

u         ,Lobular 13 

Polio-Myelitis 99 

Pregnancy,  Abdominal 79 

Pruritus  Vulvae  due  to  Vaginal 
Leucorrhcea 78-79 

R. 

Eectum,  Extirpation  of  for  Can- 
cer     59 

Bectum,  Fissure  of  the 54 

"      ,  Prolapse  of  the 58 

"      ,  Ketroflexion  with  Fis- 
eures  and  Stricture  of  the 89-90 

Begurgitation,  Mitral  and  Aor- 
tic  18-19 

Eetroflexion  with  Fissures  and 
Stricture  of  Rectum 89-90 

Eheumatism,  Acute 19 

S. 

Skita,  Transplantation  of  the 68 

Silicate  of  Lime  Splint 63 

Spermatorrhoea 94-96 

Spinal  Cord,  Sclerosis  of  the 99 

Spine,  Potts'  Disease  of  the 55-56 

Stomach,  Eum« „    52 

Strapping,  Wet- 66 

Stricture 56-57 

Surgical  Dressing 63 

Synovitis,  Chronic 60 

T. 

Tibia,  Fracture  of  the 67 

Toe-Nails,  Ingrowing 61 

Tracoma,  Acute 28 

Tympanites,  Treatment  of. 88 

U. 
Ulcer,  Th«  Chancroidal 70-71 


110 


INDEX. 


Ursemia 20 

Urethritis,  Acute,  Non-Specific,     68 
Urine,  Acute  Retention  of  the,  72-73 

Uteri,  Carcinoma 91 

Uterus,    Retroflexion    of,    with 
Hypersemia 86-87 

V. 
Vaginal  Leucorrhoea,   Pruritus 


Vulvse  due  to 78-79 

Valvular  Lesions 50-51 

Vaginismus 76 

W. 

Womb,  Submucous  and   Inter- 
stitial Fibroids  of. 79-81 

Wrist-joint,  Inflammation  of  the,    62 


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